Bent Spoon Award to Wellington Hospital

This year’s Bent Spoon Award from the NZ Skeptics has been won by Wellington Hospital for encouraging their nursing staff to claim special healing powers through the laying on of hands.

Frankly, I would be dismayed to be treated by a doctor or hospital who doesn’t recognise the important ethical or professional questions here – delusion or deception is not an acceptable basis for something which is given an approving nod by a publicly funded hospital,”says Skeptic Chair Vicki Hyde.

The Skeptics recognise that, like any form of extra caring or positive interaction from a basic smile to a relaxing massage, such “healing” or “therapeutic” touch may well make patients feel better. But they contend Wellington Hospital has stepped over the mark by trying to take advantage of a common psychological reaction and dress it up as some form of special treatment when it is not.

“Anecdotal stories and formal reports all identify a profound, disturbing lack of basic patient management and care at many of our larger hospitals, so it is particularly sad to see valuable nursing time taken up with this sort of deception, however well-meaning.”

The quest for evidence was a feature of those winning Bravo Awards from the Skeptics this year.

One such award has gone to the New Zealand Association of Rationalists & Humanists for issuing a challenge to visiting Australian Ellen Greve, aka Jasmuheen. Greve claimed not to have eaten for the last five years, feeding instead from an inner light within her deeply spiritual self.

The Skeptics have also applauded:

  • Michelle Hollis of Consumer for her June 2000 item on how to assess medical claims
  • Matt Philp, for his God’s Classroom item that ran in the Listener (April 22, 2000) examining the varying attitudes in the creationism-evolution debate and whether it is an appropriate debating point in this country’s science classrooms
  • Kim Hill, of National Radio’s Nine to Noon Programme

This year’s nomination mentioned in particular her well-balanced and informed interview of John Read, Director of Scientific Affairs of the NZ Psychological Society and vehemently outspoken critic of Dr Elizabeth Loftus and the latter’s research suggested that repressed memory is not supported by evidence.

Hokum Locum

Colon Cleansing

Thanks to reader Alan Pickmere for drawing my attention to colon cleansing. In a radio advertisement Alan heard the claim that the average adult has up to 10kg of preservatives and toxic waste in their colon. The actor, John Wayne had 20kg removed at autopsy, doubtless dating from the time spent venting his spleen against commie actors facing Senator Joe McCarthy’s inquisition. Come to think of it, perhaps he should have “vented” more often.

These accumulations are not at all surprising to a skeptical doctor as I am frequently exposed to views espoused by people whose bodies hold far more toxic waste than this and it goes all the way up to their heads. If any readers would like to cleanse their colons please call 0800-CLYSTER.

Herbs Flunk

Although it makes sense to test herbs for therapeutic efficacy, there are few acceptable trials. An Australian study of herbal and Ayurvedic preparations found that only tumeric had any anti-inflammatory effect and 5 of 23 celery preparations had an anti-arthritic effect equivalent to 50mg of ibuprofen. Given the wide variation in the bioavailability of herbal medicines I recommend stick to ibuprofen, normally taken in a daily dose of 1600mg costing around 75 cents. I bet that herbal medicines cost a lot more than that. It’s important for any useless treatment to cost a lot because that helps people believe that it actually works. (NZ Doctor 19 Jul 2000)

Swadeshi

Third world countries such as India frequently seek pragmatic solutions to their health problems and in this case they have encouraged traditional practices such as ayurveda, sidha, unani, yoga, naturopathy, Tibetan medicine and homeopathy. I was reassured to see the addition of homeopathy and naturopathy, so much a part of mainstream New Zealand medicine. The Indian Health Minister has asked all other Ministries to ensure that its employees can be reimbursed for the cost of such treatments.

Perhaps this is where our own Health Minister got the idea for allocating a large sum of money for the evaluation of alternative medicine. The increasingly third world Wellington Hospital is reduced to waving its hands at patients. Will they soon be encouraging them to start the day with a freshly steaming glass of their own urine, perhaps followed by pills made out of lama’s faeces, a traditional Tibetan remedy. (Lancet Vol 355, p1252)

Silicon Implants

As Shakespeare so eloquently put it “God has given woman one breast and she gives herself another”. Minerva (BMJ Vol 320 p 882) reports a fourth extensive study finding no association between ill health and silicon implants. However, this will not have any effect on the millions of dollars given to litigants because the standard of proof is to have one’s personal account of suffering published in any women’s magazine. In the true spirit of the post-modern age I look forward to the first litigation for alien abduction. Those anal probes can hurt! All we need is a New Zealand Doctor brave enough to fill in the ACC forms.

This is yet another example of Welch’s law: “Claims expand to take up the amount of compensation available”.

Surgeon Amputates Healthy Legs

Since I have raised the topic of post-modernism, readers will be interested in this account from the BMJ (Vol 320 p332). Both patients reported on suffered from a rare body dysmorphic disorder known as apotemnophilia which makes them believe that they can only be normal once they have had a limb removed. The patients were delighted after each had a leg removed in a below-knee amputation. The hospital administration was quoted as saying that no more of these operations will be done.

Stokabunga

Obesity has been raised to an art form in North America and it is fitting that the American food industry has launched “Stokabunga”, a cookie containing more calories than an average meal, including 48g fat. Such excess is a fitting accompaniment to a recent announcement that for the first time the number of overweight people in the world equalled the number who were malnourished. In Britain, the average cat receives more protein per day than the average poor African. Sales of Stokabunga have been particularly strong in Belgium.

Ineffective Drugs

Of the 50,000 prescription drugs currently available in Germany, 33,000 have never been subject to clinical trials. They include homeopathic preparations, herbal remedies and in one case a useless preparation containing loess (a fine soil) used for the treatment of diarrhoea. Drug companies were able to suppress a report that gave advice on how to substitute cheaper effective drugs in place of the useless ones. During World War 2, Hitler’s doctor treated him with capsules containing faecal bacteria from “finest Bulgarian peasant” and such a product is conceivably still available. (New Scientist 4 Oct 97 p20)

As recently as 1997 it was possible to receive rejuvenating injections of fetal sheep cells. This treatment was popularised by Konrad Adenaur, the German Chancellor who remained in power until he was 87 years old. Unfortunately the Germans have a bad habit of blindly following rogue Chancellors.

It is quite clear now what has happened to their Pharmaceutical Regulatory authorities. Instead of a feral and vigorous staff dedicated to removing quack remedies, the excessive use of fetal cells has turned them all into sheep in sheep’s clothing. (New Scientist 25 Jan 1997 p6)

Finger-Licking Bad For Waist Reduction?

The herb Aristolochia gangchi was mistakenly used in weight loss pills by the Kentucky Fried medicine brigade. As well as causing kidney failure it is now thought to be responsible for cancers of the urinary tract. Staff at a Belgian weight loss clinic had prescribed the herb Stephania tetranda but the mixture also contained Aristolochia which has a similar sounding Chinese name.

Dr David Kessler, former Commissioner of the United States Food and Drug Administration (FDA) notes that there are no controls over the quality of such products or their composition. The cause of this was the passage of the Dietary Supplement Health and Education Act of 1994, which deregulated the industry by limiting the role of the FDA and opening up this $15 billion-a- year industry. This ridiculous legislation does not require that dietary supplements be shown to be safe or effective. I have no doubt that an epidemic of renal failure and cancer will soon peel the weight off those hordes of fatties seen in every US shopping mall. (New England Journal of Medicine June 8 2000, p1742; BMJ Vol 320, p1623)

Tissue Samples and Cryptopathology

When confronted with unusual lumps and swelling it is a common medical practice to get some tissue examined by a pathologist and this will often reveal the diagnosis.

As a keen hunter I feel the same exemplary approach should be taken when examining phenomena such as “Bigfoot”, the Loch Ness monster and our very own Australasian “Yowie”. The Yowie is believed to be named thus after the cries recorded when it had come into contact with hunters and been wounded. It would be a matter of some pride to me if I were the first person to bag either of these trophies. Nessie would obviously require a large harpoon but depth charges would soon bring the shy and expiring creature to the surface. Bigfoot should prove no problem for my Winchester 0.243. I was therefore disappointed to read that a county in Washington has declared it illegal to kill Bigfoot. However, fur samples have been gathered from “close encounters” and delivered to Ken Goddard at a wildlife forensic laboratory. Ken found that Bigfoot has made a remarkable adaptation to its cold environment-polyester fur. Ken is waiting for a “close encounter of the turd kind” so he can examine the creature’s diet for evidence of Stokabunga. (New Scientist 22 Jan 2000 p40)

I predict that once tissue samples have been obtained, all of these secretive creatures will be found to share a puzzling 100 percent of their DNA with humans.

Forum

Wellington’s Healing Touch

I was interested to read a recent article in the NZ Skeptic on Healing Touch, as I am a consultant anaesthetist at Wellington Hospital.

When I heard this “service” was to be offered to our patients, I immediately protested to CEO Leo Mercer.

During discussion he was unhappy with what he saw as my unnecessarily adversarial stance, and felt my offer to go to the police fraud squad was not a constructive approach.

My response to him was that there was absolutely no evidence that this was a proven form of healing. He replied the personal interaction between a nurse and her patient was a vital element in promoting the patient’s welfare and recovery.

I asked why dress it up in some kind of unproven mumbo jumbo, and turn it into something mystical. I also said that if this interaction had a spiritual basis, the nursing service was promoting religion, and not science or medicine, and was therefore misusing public funds.

In reply to that he asked whether I was calling for the withdrawal of the hospital chaplaincy service, which is also at least partially funded out of taxation. I said the chaplains were employed for their religious role, and no matter who funded it, they do not pretend to be anything else. Nurses are not employed as spiritual, magical, or religious advisers, and should not take on that role.

He said much of the practice of medicine has not been proven nor subjected to formal trial or analysis, a stance I agree with. However, the failings of medicine do not defend Healing Touch or anything else. What they call for is more and better scientific research in medicine, not the acceptance of anything else.

Dr Mercer agreed to raise my concerns with the senior nurses. Nothing has happened. The courses continue, and recently a seminar on the evidence supporting the energy basis of Healing Touch was offered.

Dr Mercer has now gone the way of all hospital CEOs – away from the hospital to somewhere, anywhere, else.

But the Healers Touch on.

Graham Sharpe, Consultant Anaesthetist

Hokum Locum

John Welch started writing for the magazine in Issue 16, but a posting with UNSCOM to Iraq meant he had to relinquish responsibility for the column. He is delighted to once again have the opportunity to indulge his interest in bizarre medical beliefs and wishes to thank Dr Neil McKenzie for his efforts to date.

Craniosacral Therapy

Manipulative therapists such as osteopaths and chiropractors continue to provide a rich source of deluded ideas. Here is Clemens Franzmayr writing in NZ Doctor (10 May) on the treatment of dizziness: “Colleagues experienced in craniosacral therapy have good results by freeing tentorium cerebelli from restriction and by mobilising the temporal bone on the disturbed side, including the ear pull.” For once I am in complete agreement but I have always obtained far more impressive results from the “leg-pull.”

The good Doktor goes on to say: “with one single manipulation of the upper cervical spine the patient could be free of all complaint.” The patient could also be dead from spinal cord damage due to the wholly unnecessary and unscientific intervention.

Medical Overinvestigation

Your correspondent has been recently refreshing his medical skills in the Casualty Department of a large urban hospital where many of the patients present with trauma due to alcoholic decelerations. It is fascinating to experience the change in attitudes due to medicolegal fears and the consequent extensive use of sophisticated investigations such as radiological imaging techniques, recently satirised by one writer as the “gropagram”. However, a note of caution. When arriving at the hospital please do not ask for your NMR (Nuclear Magnetic Resonance) as I fear you could experience a nasty rectal invasion by an agency nurse from Sri Lanka. (New Scientist 17 April 99).

Fraudulent Skin Treatments

There is widespread belief and acceptance of treatment with secret mixtures by a section of the community who do not understand that such preparations are not subject to any form of scientific testing, standard or even basic tests of efficacy. A London clinic sold a 50g pot of cream that cost $2000 which was found to contain white paraffin and a small amount of the steroid fluocinolone, sold in New Zealand as Synalar and costing $5.92 for 30g. The great irony here is the use of a powerful and effective remedy secretly used within the context of quack therapy. Herbalists, not to mention Homeopaths, will no doubt join me in general indignation at this totally unethical behaviour.

This “Kentucky Fried medicine” (secret herbs and spices?) is a perfect accompaniment to the age of post-modern consumerism. One Wellington GP has even received approval from the Medical Council to sell similar products to her patients.

I wish I had patients like that when I was in General Practice. Even Dermatologists would envy me earning over $100,000 a year from the sale of one pot of cream a week. Damn that troublesome conscience; I could have been rich!

Analysis of Chinese herbal creams

Patients with chronic problematic skin conditions often resort to herbal remedies which are seen as “natural” and therefore safe and free of side effects. Since chronic skin conditions are commonly treated with potent steroids there are genuine concerns about side effects. Some researchers (BMJ 1999;318:563-4) found that eight out of eleven herbal creams contained dexamethasone, a potent topical steroid.

I know it’s fraud, but I still find it amusing that people using a “natural and safe” herbal remedy are in fact gaining relief from a potent nasty dangerous steroid, normally prescribed by nasty dangerous doctors in the pockets of multinational drug companies. Me paranoid? I know they are out to get me!

This reminds me of a very popular cough mixture in the early 1900s whose “magic” ingredient was heroin.

Chicken Soup

Two Israeli doctors are calling for the World Health Organisation to include chicken soup on its list of essential drugs. This will come as a great burden to the inhabitants of many Third World countries where the daily walk for water will now have to be extended for chickens. Since the WHO already lists a variety of conditions amenable to acupuncture, including myopia, the inclusion of chicken soup is entirely appropriate as an unspecified remedy for whatever ails you. Don’t be put off by the lack of evidence — “Chicken soup is over 2000 years older than the randomised trial.” They said the same thing about acupuncture.

I can assure readers that chicken soup will cure anything if you strongly believe that it will. Disclaimer: I have no shares in any chicken soup companies.

Dental Amalgam

Readers will be pleased to hear of the retirement of one of the worst medically qualified quacks in recent memory. This individual who cannot be identified for obvious legal reasons, used a dental amalgameter to diagnose “mercury poisoning.” This fraud was practised on countless patients who then paid to have all of their amalgam fillings removed, a practice condemned by the Dental Council as there is no link with any form of illness and the number of such fillings. I have written before on the subject of dental amalgameters which are basically a fraudulent blackbox device of the type discussed at our last conference. (See lead article – ed.)

This quack also railed against immunisation which prompted me to write a letter of complaint to the Medical Practitioners Disciplinary Committee (MPDC) who are essentially toothless when dealing with quack doctors. I was informed anecdotally by the MPDC that they had received dozens of complaints about this individual but were powerless to act unless they received a complaint from an actual patient who had been harmed. The MPDC forwarded me a copy of the doctor’s reply and if anybody would like a copy please send me a SAE. It is a fascinating, self-deluded and paranoid document from which I have deleted any identifying details.

Rudolf and Bailer, psychologists at the University of Heidelberg, looked at 40 patients who claimed health problems connected with their amalgam fillings. When compared with other people with amalgam fillings but no such complaints there was no correlation with any measurements of mercury in blood, saliva or urine. The researchers found that the complainants had histories of psychological problems, were emotionally unstable and had an obsessive attitude towards their health.

I have a mouthful of amalgam fillings and my health is perfect. I rest my case.

Buteyko and Asthma

The Buteyko breathing technique (BBT) is merely one more of a long line of quack therapies for asthma. (Try the medieval remedy – powdered fox lung.) Central to the theory is the belief that all patients with asthma hyperventilate (over-breathe). Deliberately slowing breathing increases carbon dioxide levels which could dilate restricted airways. However, the overwhelming scientific consensus is that asthma is an inflammatory disorder. Since quack treatments are seldom put up for testing, I was surprised to read of a trial of BBT reported in the Lancet (1998; 352:1993). It flunked. Although BBT patients were able to reduce their medication there was no objective change in key indicators of lung function. This is not at all surprising as patients receiving acupuncture treatment for asthma also reported marked improvement which was not confirmed by objective measurements of lung function. This is the classic placebo effect which is the cause of perceived improvement in most alternative medical treatments.

When people strongly believe in something and that belief becomes an unshakeable faith, they are immune to reason. When the above results became apparent the researcher from the BBT Clinic withdrew her authorship from the paper.

A Bitter Pill?

The risks of third-generation contraceptive pills have been much in the news. But assessing risk can be a tricky business.

Twenty-nine years ago, I was about a week into my first job as a doctor, as a House surgeon in orthopaedics at Guy’s Hospital in London. I had not had time to get to know the patients under my inexpert care and was on a very steep and stressful learning curve. Just before three in the afternoon as I was doing my post-operative round, my bleep went mad, warning me of some dire emergency. I hurried to the men’s ward to find an anaesthetist and another doctor working hard to revive a man who had suddenly called out and then fallen back pulseless. He had had a knee operation the week previously, before I had arrived on the job and I scarcely knew his face, let alone his name. My puny contribution to the efforts of the experts were to no avail and his circulation could not be restored. His wife was waiting outside and it fell to me to tell her that he had had some sort of heart attack and had died. You will not be surprised that it is her face rather than his that I remember.

Twenty-five years later, another patient in my charge, a young student of twenty, had puzzled two other doctors by her sudden attacks of loin pain over several weeks, first on the right side, then on the left and then on both sides. By the time she came to see me, she had had numerous blood tests, an emergency kidney x-ray and a chest x-ray. They had given no clues as to the cause of the pain. She had been seen in the Accident and Emergency department of the local hospital in the middle of the night. She had been seen by a colleague of mine at the weekend. The attacks continued, but in between them, she had been well enough to go out on Territorial Army manoeuvres. When she saw me, the pain was bad enough to make her catch her breath. Apart from severe muscle spasm and a raised pulse rate I could find no abnormality. I noted that “something strange is going on here.” I arranged for her to see a medical specialist urgently. Before she could keep the appointment, while walking from the library to the cafeteria, she fell pulseless to the ground and her circulation could not be restored.

Venous Thromboembolism

Post-mortem examinations showed that what both these unfortunate people had in common was deep venous thrombosis and massive pulmonary embolism, first elucidated by the great German pathologist Virchow, well over a hundred years ago. Venous thromboembolism, as it is often called, VTE for short, has vexed doctors ever since.

Most of you will know that blood outside the body clots. It is fortunate that while in the blood vessels it does not usually clot unless the vessel is damaged and then clotting is indispensable. The damage results in the release of substances that initiate a cascade of biochemical reactions that result in a tangle of a fibrous protein called fibrin, mixed up with platelets and red blood cells. This plugs the hole in the vessels and may plug the whole vessel. Virchow’s triad has stood the test of time as an analysis of what happens with abnormal clotting. He observed that the main influences are disturbances of the vessel wall, things that change the dynamics of the blood flow and things that change the components in the blood that initiate clotting. Let us return to my two unfortunate patients.

Contributing factors

In the case of the first, he had had an operation on a lower limb and his limb had been immobilised in plaster. The stress of an operation in itself increases the clottiness of the blood, muscle action would have been absent during the operation and reduced after it, leading to sluggishness of flow. We can imagine what happened in the veins of his legs with clotting extending from a vein, often starting in a valve pocket, and eventually extending into the main vein of the leg and thence even into the main abdominal veins. Eventually, a large piece broke off, was pumped through the right side of the heart, blocked the pulmonary trunk and brought circulation suddenly and permanently to a halt.

The second person was a fit and healthy young woman. Were there any known predisposing factors? Had she perhaps an inherited predisposition for her blood to clot easily? Her grandfather had had an uncomplicated deep vein thrombosis after an operation on his leg, but this is a known risk. Had she had any injury? Well, she had sprained her ankle on Army manoeuvres four weeks before she had started to get symptoms. Following her death, her Lt Colonel investigated this and there is nothing in his detailed account to suggest that she had anything other than a minor sprain.

She had not sought any medical attention for it. And three months previous to her death, she had started to take the contraceptive pill.

Popular Pills

The first major trials of the contraceptive pill took place in the late 50s and it quickly became very popular because of its ease of use and near 100 percent efficacy. It contains two hormones, progestogen to fool the pituitary gland into thinking the taker is pregnant, so that it has no need to send signals to an ovary to release an egg; and oestrogen to give cycle control so the taker can have a monthly pseudo period. The oestrogen component also reinforces in some way the contraceptive efficacy of the pill. The first pills used about six or seven times as much oestrogen hormone as modern pills and the first case histories suggesting an association between the pill and VTE appeared in 1961. A report to the British Medical Research Council in 1967 showed a clear link between pill use and VTE and further papers from Britain, Sweden and Denmark in 1970 concluded that the risk of thrombosis was linked to the oestrogen dose. By this time, the oestrogen dose was down to about 80 micrograms from an initial 180 to 200 micrograms and it was then recommended that the level at which risk became unacceptably high was about 50 micrograms of oestrogen.

Absolute Risk

Early case-control studies suggested that the risk of VTE was between two and eleven times greater in pill-taking women and the absolute risk was between three and six episodes per ten thousand women per year. A large study of 65,000 women in Seattle in the early eighties suggested a relative risk of 2.8. Healthy women not on the pill seem to have an absolute risk of about one per thirty thousand women per year, so the risk in pill-taking women is about one per ten thousand per year. I should make it very clear at this point that we are not talking about risk of death here, but only of deep vein thrombosis. If we take the worst figure, about one in fifty of people who get deep vein thrombosis will have a fatal pulmonary embolus, so the risk of death from this per year of pill use is about one in a quarter of a million per year. However, a further proportion of people who get DVT will have permanent damage to the veins of their legs and in some, multiple small clots breaking away will cause permanent damage to the circulation of the lungs. Pills containing progestogen on its own do not seem to have an increased risk of VTE, but are less effective and periods are irregular, so they are less popular.

Late in 1995 media reports began to appear that so-called third generation oral contraceptive pills carried a greater risk for VTE than the older pills. The third generation pills contain the progestogen hormones gestogene or desogestrel, which can be thought of as designer hormones. The state of the art of drug synthesis has advanced to the point where the properties of the hormones can be to some extent predicted from their structure, and vice versa, and these two hormones have fewer male-hormone like effects (such as causing acne etc) and less effect on fat and carbohydrate metabolism. They were promoted as being safer for the arteries, where blood clots also occur, as in heart attacks and strokes, and better for the skin. It was difficult for doctors to advise their patients as the papers on which the media reports were based had not been published, but three eventually appeared in the scientific medical journal, the Lancet, of December 16, 1995 and another one in the British Medical Journal in January 1996. They are not easy reading and I think it is safe to say that those most likely to prescribe the contraceptive pill, general practitioners, do not as a rule read the Lancet.

Literature Reviews

Fortunately for us, there was no shortage of secondary articles, and one appeared in the Ministry of Health’s Prescriber Update in February 1996. I have read the original papers and can say that the article is an excellent and balanced summary that accurately reports the findings of the originals and correctly reflects the views of their authors. The risk of VTE in second generation pills is less than previously reported. A healthy woman who is not a current user of the pill has an annual risk of VTE of about one in 26,000. A woman who takes the modern second generation pill has an annual risk of about one in 6 to 10,000. Someone who takes a third generation pill has an annual risk of between one in 3,570 and one in 5,000, so the risk of VTE in third generation pills is roughly twice that of second generation pills. The authors echo a Lancet Leading Article in stressing “that further independent study is necessary. The interpretation of the small increase in risk of VTE must be weighed against a possible decrease in the risk of other cardiovascular endpoints. Until the relative risk of other important health outcomes such as stroke or coronary artery disease.. is clarified, there is no sound basis for recommending any change to current contraceptive practice.”

British Response

In Britain, the response of the Ministry of Health was to advise that the third generation pills should not be used by women with additional risk factors for VTE and that doctors should prescribe them only for women who were prepared to accept the increased risk and who were intolerant of other combined pills. This led instead to widespread flight, not only from third generation pills but from contraceptive pills in general, with at least anecdotal reports of many accidental pregnancies and an increase in abortions. This may seem very strange to aliens like us who habitually think logically, but you will not be quite so surprised if I said that following a recent total solar eclipse in Britain, people sought advice as to whether viewing the eclipse on television could have caused damage to their eyes…

In New Zealand, the response was more muted. Doctors took the advice from the Health Department at its face value and received it as a reminder to check for risk indicators when prescribing the pill. In December 1998 we were told between January 1993 and June 1998 there had been six deaths from VTE in women taking the third generation pills whereas between 2.2 and 3.7 deaths in this time would have been expected. Of course, with such small numbers the figures could readily be accounted for by random variation and the article pointed out results from epidemiological studies are more reliable than Committee for Adverse Reactions Monitoring data. The waters were by now quite muddied and Sandra Coney jumped into them last year to further stir them up when the headline of her column in the Sunday Star Times read “Who’s to Blame for Pill Deaths?”

“My question is”, she wrote, “who is accountable for these deaths? Is it the drug firms who raised the spectre of legal action against the Ministry when it planned to issue warnings when the risk of these pills were first known?

“Is it the medical groups who pressure the Ministry by saying they would disassociate themselves from the advice? Or is it the various officials of the Ministry of Health who caved in under the pressure, selling New Zealand women down the river?”

She pointed out that “an astounding 75 to 80 percent of women” using the pill in New Zealand were on third generation pills. “This”, she said, “tells us something about the too-cosy relationship between doctors and drug companies in New Zealand.”

According to Coney, the Adverse Reactions Committee had advised doctors should preferentially prescribe the older second generation pills, but the pill manufacturers threatened the ministry with legal action and had “bombarded GP’s with dossiers contradicting the studies” and the Royal New Zealand College of Obstetricians and Gynaecologists said they would publicly dissociate itself from the advice. The Family Planning Association, another body that might be thought to have some expert knowledge too, “went about saying the studies…were affected by biases so that the results couldn’t be trusted.”

Rhetorical Questions

At the end of her article she asks questions that might be thought to be mildly rhetorical given the general tenor of the article. Of women using third generation pills she asks:

Are they warned of the risks?

Do they know that they could reduce their risk by using older forms of OC’s or even eliminate it by using another method?

Have their doctors explained to them the symptoms of blood clots?

Do they know they are at additional risk if they are immobilised because of illness, injury, surgery or a long plane flight?

What must we poor benighted doctors do as dossiers rain down about our ears from drug companies, as sticks labelled “informed consent” are waved at us by the Health Commissioner, as our expert bodies display their ignorance by echoing the advice given by other expert bodies throughout the world?

The publicity has had a beneficial effect in making us more careful in assessing people’s suitability for the combined pill, but it may have led us to practice a more defensive style of medicine. In a consultation I have about twenty minutes to impart quite a lot of information and know that seventy percent of what was absorbed at the time will have been forgotten by the end of the day.

Reduced Risk?

Could they indeed reduce their risk by using an older pill? One expert, Walter Spitzer, commenting in the Lancet on a World Health Organisation scientific summary writes “The summary of the conclusions plays down the controversies that have raged for the past two years about differences between second and third generations of oral contraceptives in risk of VTE. It also properly emphasises the rarity of all the three serious side effects.” He went on to point out that there is at least some evidence that third generation pills may have a smaller incidence of heart attacks in young women and that the order of risk for VTE and heart attacks is about the same. What we may gain on the swings of reduced VTE we may lose on the roundabouts of heart attacks.

If we look at risks in isolation we may reach conclusions that are both correct and yet which are absurd. Let us suppose that a sexually active woman decides that the risk of OCP is too great and so she uses no contraception at all. In a year she has a seventy percent chance of getting pregnant. During the pregnancy she has a one in 1600 chance of getting a DVT and during the week in which the baby is born a risk of about one in six hundred, roughly ten times greater than the worst risk for third generation pills – if the studies have reached a correct conclusion.

Symptoms

Every third year medical students knows the symptoms of blood clots. You get a painful swollen leg with tender calves. Unfortunately for us poor benighted doctors and unfortunately for our patients, most people with DVT don’t have these symptoms and most people with these symptoms don’t have DVT. Pulmonary embolus is even more difficult to diagnose without high tech help – except in the post-mortem room. Oh, if only the drug firms would distribute free retrospectoscopes instead of raining dossiers of propaganda on me! Still, I do tell patients, orally and in writing, about painful swollen legs; and chest pain with shortness of breath and spitting of blood; and about sudden loss of vision or use of limbs. If I set a test at the end of a week not many would pass. But I’ll be OK when the Health Commissioner comes calling.

Do I really have to tell them about additional risk if they are immobilised because of illness, injury, surgery or long plane flights? My elder daughter flew to Britain a few months ago. Would I as a doctor expect her doctor to suggest that she stop the pill (I don’t know whether she’s on it. It’s none of my business). First of all, long distance flying carries a risk of DVT that is independent of being on the pill, so I should also expect him also to warn her about the risk of cosmic rays at high altitude, the risk of side-stream smoke in the cabin, the risk of acquiring hepatitis A from eating airline food and so on almost ad infinitum. In any case, it’s a risk that she would run for a few days at most, so it would have to have a very high annual risk indeed to be of comparable significance to the annual risk from the pill.

To Sandra Coney and others the issues seem to be simple. One sort of pill carries twice the risk of another sort. Drug firms have bullied the Ministry of Health and have muted the voice of doctors and other experts by stopping their mouths, not with gold, the preferred substance for scoundrels down the ages, but misleading dossiers. A risk is a risk is a risk and no one should have to run it if it can be reduced. No matter that people vastly better informed and experienced in analysis of statistics comment about the “lack of clinical importance and public health significance of VTE” with its “very low absolute rate of occurrence, low morbidity and low case-fatality.” Nothing must get in the way of a good story.

The Global Messenger Hoax And The Misinformation Economy

At last year’s conference, John Scott spoke on the problems of mixing misinformation and medicine.

Early in my medical career I became aware of the enormous distorting forces which operate upon science in the real world. In my field the forces were those of Quaker Oats, Kellogg, Sanitarium, the diary industry, the AMA, elements within the cardiology camp, and the tobacco giants. I became an interested observer of some enormous investments in dubious research projects, many of which could only be termed con-jobs. More particularly, I realised that we scientists were very human creatures.

Together with many of my colleagues I plodded along trying to inculcate into oncoming generations of medical students a genuine understanding of scientific principles and methods. To be frank, my generation of teachers has failed, certainly as far as the bulk of medical graduates is concerned. Events over the past year in England, Europe and New Zealand have rammed that point home, often in painful ways, as far as I am concerned.

I do not wish to be seen to disparage many of the achievements of scientific and technological medicine over the past thirty to forty years. They have been massive. However, other huge investments in the health-disease industry deserved to be challenged and remain in that situation.

The central message so far is not news to this society. Bill Morris gave a paper at the Palmerston North meeting challenging much of the classical diet-coronary heart disease hypothesis. His voice was about as lonely as mine at that time. Science ultimately makes advances by gaining improved understanding of mechanisms. There is nothing wrong in doing one’s best with available knowledge until one obtains comprehensive understanding of a particular situation.

Coronary artery disease and arterial disease generally present very complicated problems. Fortunately and unfortunately, in an exquisite paradox, arterial disease is a very general phenomenon and becoming more so as countries become steadily more affluent.

There is enough knowledge to make a reasonably firm statement of dogma, that the causation is multifactorial and represents an interplay between environment and one’s genetic endowment. This statement doesn’t help a great deal about developing techniques for elucidating mechanisms. It does, however, provide wonderful protection for less competent scientists and technologists, and certainly, for industry generally.

New Technology

The cholesterol-saturated fat-diet-arterial disease hypothesis really took off when the 19th century concepts concerning the potential of computers were made possible through the development of transistors and printed circuits. In turn, epidemiology was provided with a tool it had needed. The autoanalyser had also been invented and thus mass biochemistry was now possible.

What amounts to an industry with a turnover through the decades of trillions of dollars was really set alight by a gentleman called Ancel Keys. He undertook studies in Europe linking what amounted to death certification and some relatively crude morbidity data with the local diet and estimates of cholesterol levels.

Here we get into what I term the “global messenger hoax”. On a simple arithmetical biaxial plot, Ancel Keys’ data, from his various countries, was the traditional dog’s breakfast. Subsequently one of his senior technicians, who was extremely troubled by what happened, published the truth.

In turn the technician’s article was immediately suppressed pretty effectively by the scientific juggernaut which had developed around this particular health-disease industry. Ancel Keys had selected a series of points which produced a straight line on a semilogarithmic plot or a gentle smooth curve on semilogarithmic axes.

I was aware of this at the time but didn’t get very far in quoting it, although, to his credit, the later Sir Edward Sayers accepted that Ancel Keys had at least been naughty. However, eventually a very prominent American nutritionist and professor of medicine, Dr Feinstein, published the original material plus Ancel Keys’ simplified extrapolated data which had set the whole bandwagon rolling. Feinstein came into the scene too late. He was too big a Don Quixote to be rubbished, so he was therefore largely ignored.

Now there is nothing particularly unusual about all that. As is eminently predictable, history is catching up with the epidemiologists who have continually reinvented the Ancel Keys wheel. Basic scientists, particularly anatomists, pathologists and immunologists, with their analysers and biochemistry, have begun to get at the common pathways upon which genetics and a complex environment interact to produce arterial disease. The gross simplifications have been exposed. Interestingly, however, the process continues of twisting results of recent research to fit the theory at each stage of the wheel reincarnation.

Alternative Interpretation

Most of you will know about the statin drugs which are very powerful reducers of cholesterol levels. Probably a majority of my colleagues believe that the advent of these drugs and their testing on a massive scale by people, including me, has vindicated the cholesterol hypothesis.

However, it might interest you to know that Brown and Goldstein, now working in Southwestern University of Texas, have a huge group of scientists and technologists exploring alternative interpretations.

If it was possible for physicians and epidemiologists to remove their dogma spattered spectacles, they would see what is obvious from most of the large statin trials, particularly the much hailed 4S or Simvastatin study. The effects of morbidity and mortality were proportionally just as great for the group at the bottom end of the scale of cholesterol elevation as they were for the top end.

If one thinks that through carefully and reanalyses the evidence, something else is going on than mere lowering of cholesterol and low density lipoprotein. There is no real surprise in that, when one looks at the nature of the intervention in the cholesterol synthesis pathway, and links that to the ubiquity of cholesterol as an essential structure which holds many biologically important molecules in a particular spatial pattern.

Cholesterol is involved in many biochemical processes and synthetic pathways. The statin drugs do many more things than just lower elevated cholesterol. But the message proclaiming the dogma is out there, and the messengers are not going to change their message in a hurry without carefully considering the shareholders’ interests. After all, the drugs do have a demonstrable effect and are eminently marketable even on the basis of partial evidence.

That brings us up against the real problem and my choice for the title of this talk. We live in an age of misinformation. Politicians seem oblivious to that as they play gleefully with the bubbly toy of the knowledge society concept.

Political games not withstanding, we are all in on this mass-deception exercise. When I thought about applying to the then Mr, now Sir Douglas Graham for legal aid to support the skeptics in a crusade against the pervading partial truths and cunning deceptions, I realised that he probably would remove his pipe temporarily and mumble something about the stability of societal constructs and the impoverishment of lawyers generally.

When more recently I wondered about approaching the Hon Tony Ryall, I realised that I might receive a lecture on fundamentalist thinking. He might use the biblical quote, “You who are not for us are against us.” Moreover, if I took my protests elsewhere I would be rapidly caught up with various religion-based aphorisms. You seek to be a prophet in your own country, haven’t you read the bible?

Shooting the Messenger

These musings sent me off on another trial as the green lipped mussel saga developed. I happen to know a lot about these tasty beasties, because work on them was undertaken in the Department of Medicine in Auckland during the time that Derek North and I were HODs.

Once again, it’s the messenger business that interests me. I happen to believe that Susan Wood is a more astute and intelligent anchor girl than Holmes, allowing for gender-bending bias. However, it rankled me that she and the editor of the New Zealand Herald both came out with the all-innocent line – “Why attack me, I’m only the messenger,” to paraphrase things. A spokesperson for the Ministry of Health understood that he was being snowed by Susan Wood but didn’t quite get his counter-attack launched correctly. The Herald seems to have got away with it more or less completely.

However, there is a huge message within that message. The media are not just the messengers. They are an integral part of the process of the misinformation economy. New Zealand is, for at least half its population, a comfortable consumer society, seemingly happy to buy more than it can afford. The United States is going the same way as evidenced by this month’s trade deficit.

If we analyse that situation further, it becomes pretty obvious that what might be termed scientific truth, in itself certainly not an absolute or a constant quality, is now a debased commodity. The concept of quality of information which members of the Skeptics believe to be an essential prerequisite for intelligent human advancement, is held in contempt by key players in the global economy.

Evidence of Efficacy

It is all very well for the Medical Council of New Zealand to pronounce that there is no difference between orthodox and traditional or nonorthodox therapies, their common attribute being that any claims they make shall be based upon evidence of efficacy.

That sounds fine but it flies in the face of reality. Unfortunately, the failure of people like me as medical educators receives poignant testimony from the increasing use of acupuncture, homeopathy and so forth, by so many of our graduates.

Moreover, the status of a critic of these mixed practice habits is weakened by the continuing paucity of sound justification for many so-called orthodox practices. However, thanks to the financial seduction of the messengers, downgrading of science is now a fashionable global activity.

Occasionally I tune in before the 6pm TV1 news and there is the lady representing Blackmores coaxing me into upsetting my gastrointestinal system with slippery elm and to exposing my nervous and renal systems to potential chaos as I ingest mixtures of herbs, some of which contain quite toxic compounds.

I have carefully avoided quoting from the genetic engineering debate but you all know that I am heavily involved in that as president of the Royal Society and in defending science and technology. In particular that society is trying to ensure that information across the spectrum of opinion is made available to the New Zealand public.

We have done a bad job in this, because we failed to estimate the strength, political nouse, and financial capacity of the opposition, that is, of the anti-biotechnology anti-genetic engineering lobbyists, particularly in Europe, England and now New Zealand.

Is this little diatribe of any relevance? I believe there are two important aspects to the great global messenger hoax and the misinformation economy. A lot of harm is being done to people who are not in a position to understand what is happening.

As soon as I make such a statement, I am immediately assailed by the various groups which benefit financially, or in terms of personal status and so forth, because I am becoming paternalistic in a traditional manner and seeking to impose my restrictions on their freedom of choice. However, let’s take that a wee bit further.

To me it is heartening to see Sandra Coney and Robyn Stent opposing one another publicly over the issue of patients’ rights in relation to Lyprinol. I further applaud Dr Pippa MacKay in joining the fray in the New Zealand Herald. I suspect that newspaper does feel guilty about its part in the $2 million one-day killing, but that guilt won’t last for long. Why then are these issues important?

Vaccination Alarms

In 1998 reports began to circulate that measles, mumps and rubella (MMR) vaccination might cause autism, possibly through a mechanisim involving changes in bowel function.

There were immediate notes of caution sounded but they were largely ignored. It was pointed out that the reported cases might have been due to what is termed temporal coincidence. There was certainly no convincing laboratory evidence for the contention. A specially convened United Kingdom Medical Research Council committee found the so-called clinical evidence unconvincing.

However, the media messengers got into gear and there was a definite drop in acceptance of MMR vaccination in the United Kingdom. That has spilled over into New Zealand and added fuel to the anti-vaccination campaign here.

This is what I mean by people being harmed by what I have termed the global hoax of purveying partial or pseudo scientific information, to gain readership or viewing numbers for the profit of the moment or for political advantage. Infants and children are in no position to give informed consent, their parents are well placed to be misled.

Information Ignored

I use this particular example because the press internationally ignored information available at the time of the initial sensational reports, which indicated that the measles virus was not the mechanism for the observed cases of inflammatory bowel disease (IBD). There was thus selective reporting for purposes of gaining sensation.

I believe that in June 1999 The Lancet laid the matter to rest with the advent of further information. The Lancet also says in its edition of June 12, page 1988 that:

Will the scientifically sound and essentially ‘negative’ results published this week garner the same media and public attention as the initial report of the MMR-autism hypothesis? It is unlikely, as evidenced by the renewed media frenzy last week in response to another report by the group that proposed the hypothesis. This report was of an increased risk of inflammatory bowel disease among individuals who had naturally acquired measles and mumps within one year of each other. The study had no data on MMR vaccine and the investigators specifically stated that they did not find a significant relation between monovalent measles vaccination alone and later IBD. Yet the popular media trumpeted the study as providing evidence that MMR vaccination may cause IBD. In such an environment it is critical to strengthen vaccine safety monitoring systems and risk-communication strategies to maintain public confidence in immunisation.

Lancet Editorial Comment, by F De Stefano and RT Chen, 1999, Vol 353, pp 1987-1988

Thus I believe the first important aspect of all this is that the misinformation distribution process can be harmful.

The second important aspect relates to what the whole process tells us about ourselves as a collective society. In a New Zealand which is seemingly increasingly non-numerate to an effective degree, and increasingly less literate in the classical sense, we do face a problem and may need more than legal aid to save our society from contemporary ridicule emanating from better educated international competitors, or worst fate of all, transformation into a nation dominated by a media worshipping cult.

I don’t blame the media for what is happening – I blame ourselves for our failure to anticipate the consequences which automatically ensue when the information technology explosion hits an unprepared, untutored, non-critical society.

We skeptics do have a role – we need to decide how to change the pattern of which I am, I believe, justifiably critical, such that New Zealand can reach democratic decisions on a basis of roundly presented, soundly analysed, best available information.

Can we, the skeptics, help disprove the hypothesis of HG Wells who wrote in 1920:

Human history becomes more and more a race between education and catastrophe.

Hokum Locum

Joint Manipulation

An article in NCAHF reminded me of past activities with respect to joint manipulation. Following a one week course I embarked on a short-lived career in spinal manipulation which is very easy to learn and causes a greatly inflated belief in one’s ability to “cure” spinal ailments.

The first problem was that patients kept coming back repeatedly to have their back or neck “put back.” I soon realised that if, as the quacks claim, the spine can easily be “put back” then it can just as easily “go out” again. All I had done was create a perception with the patients that every time their back or neck hurt it required a specific manipulation. If only I was more unscrupulous…what a wonderful money-making idea!

What finally cured me of such activities was the day I manipulated a patient’s neck with the usual psychologically satisfying crack from the spine. She sat up, went pale and slumped back onto the couch. Distraught, and thinking that I had killed her I rushed through to get the assistance of my receptionist who took one look and said to me “You twit. She’s only fainted.”

As a reformed manipulator, I was therefore interested in the following which I will quote in full:

“The popping sound associated with ‘putting bones back-into-place’ (though it may be accomplished by manipulating a normal joint) is one of the cleverest and most effective forms of suggestive therapy ever devised. This has a tremendous psychological influence over the mind. While the popping sound itself is quite meaningless, this influence might possibly be used to advantage in curing psychosomatic conditions — provided the patient is informed that the bone is ‘back-in-place’ and will stay there. By the same token, however, such treatment can cause a great deal of harm; that is by perpetuating a psychosomatic condition or even creating a new psychological illness.”

Manipulative therapy is well documented as leading to spinal cord damage and paralysis. Quacks will claim that this only occurs in a few cases per 100,000 patients treated but the easy answer to this is that all of these conditions get better without the risk of paralysis from manipulation, therefore any risk of spinal cord damage is unacceptable. (NCAHF Vol 18, No 3)

Alleged Allergies

Although I don’t see many children in the course of my work, I am amazed at how often mothers allege that their children can’t have milk because of various allergies. In one study, researchers found that people who perceive that they are allergic to milk simply misinterpret ordinary abdominal feelings. From a group of 30 subjects, 21 were identified who were genuinely intolerant of lactose. They were divided into two groups and given either normal milk or lactose-free milk. There was no difference in the amount of abdominal distress reported by the two groups.

Full of Wind?

A report on a new breathing therapy for asthma initially looked quite interesting until I came across the following statement: “by learning to saturate their bodies with carbon dioxide, patients can lessen muscle tension and slow breathing to a normal rate.” After reading this I was still interested until I came to the end: “the technique is also used to treat angina, high and low blood pressure, piles, varicose veins and even cancer.” This is an absurd range of indications for any one treatment and such claims are absolutely diagnostic of quack therapies.

Carbon dioxide is one of the most potent stimuli of the respiratory centre which triggers breathing. Any attempt to saturate the body with carbon dioxide will stimulate the breathing reflex so the whole therapy concept is a contradiction in terms.

Silicon Implants

Are there any American female actors who have not had their breasts surgically enhanced? I was reading a magazine which was profiling Baywatch star Pamela Anderson. Pamela cannot stay in cold water for very long because her implants start to solidify and ruin her mammary profile.

In Skeptic 34 I outlined how women could claim for silicon disease if they had vague symptoms such as chronic fatigue, muscle weakness and memory loss. A study reported in the British Medical Journal (Vol 311, p138) found no connection between silicon breast implants and connective tissue disorders.

Gulf War Syndrome

A study of 10,020 Gulf War veterans found that the range of complaints they had was no different to the general population. I imagine that this conclusive study will not settle the matter as long as there is the prospect for compensation. There was very little actual fighting in the Gulf War and more Americans were killed in accidents than in actual combat.

Like most sensible people in the military, I am opposed to ritual combat as a means of solving disputes. In future wars, I can see soldiers going into battle followed by support companies of psychologists and counsellors, available to give emotional first-aid following the shock of finding that the enemy are firing live rounds.

The American study confirmed a British study of 45,000 soldiers which concluded “no evidence has emerged that any organic disorder has occurred more commonly in Gulf veterans than in any similar population over a similar four year period.” Hopefully this will be the last we hear of “Gulf War syndrome.” (GP Weekly 16/8/95, BMJ Vol 310, p1073)

Size Does Matter!

Before being released from prison, convicted sex offenders in the UK are being subjected to penile plethysmography (PPG). PPG detects minute changes to the penile blood supply while the prisoners are shown sexually explicit material. Sexual arousal is defined as a “deviant response”. The psychologist in charge of this program claims that the scientific literature says that the test is “valuable”. Another psychiatrist condemned it as a “gross abuse of human rights”. As a rational skeptic (after Skrabanek) I suspect that PPG is an unproven and extremely unlikely test which is likely to have a very high false positive response. Sexual arousal in males can occur at all sorts of embarrassing moments and it is likely that most males would show a degree of arousal when exposed to sexually explicit material. (Christchurch Press 1/6/95)

Berry Silly

The Auckland Sunday paper (27/8/95) carried a small article which claimed that World War Two airmen improved their night vision by eating blueberry jam. This contains “anthocyanosides” which are alleged to improve night vision and treat visual fatigue. It is no surprise that a drug company is now marketing pills containing this substance. This is another good situation for Skrabanek’s rules. Is this claim at all plausible and is there any more likely explanation for claimed improvements in night vision? Clearly, the placebo effect is at work here and no further testing is warranted.

Quackery and Chemists

If you go into the average chemist’s shop you will often see displays of homeopathic remedies along with vitamins and other dubious preparations. Most chemists derive the majority of their income from OTC sales and if they didn’t sell these things, someone else would. I draw the line, though, when chemists start promoting quack ideas and remedies.

A member handed me a newspaper clipping which quoted a chemist as saying “zinc detoxifies chemicals like alcohol, improves behavioural problems such as depression, anorexia, bulimia, fatigue and loss of libido.”

Prior to rushing off to get some zinc, readers will be pleased to know that there is a simple test for zinc deficiency. A sip of zinc septahydrate solution is held in the mouth and “from the taste the zinc level is determined.” I tried it and got a taste reminiscent of bullshit.

I forwarded this clipping to the Pharmaceutical Society of NZ and got the following reply: “whilst not every pharmacist would share these views, it is not considered that they bring the profession into disrepute. There have been many studies carried out on zinc which would appear to support the general thrust of these claims.”

Sick Building Syndrome (SBS)

Investigators have finally done the obvious and looked at buildings for which there are no complaints of SBS. Measured levels of contaminants were low and the authors found that complaints about the working environment were related to “perceptions about air movement, dryness, odours and noise.”

As I have said before, SBS, like CFS and OOS, is based on a notional but false belief that psychogenic symptoms have some exterior cause. The availability of compensation completes the picture although, in the case of SBS, compensation is not available for any occupational disease associated with air-conditioning and this is probably why there has not been a flood of claims.

Occupational health workers continue to perpetuate false ideas in their own literature because they lack a perspective on history and human behaviour. The Lancet (Vol 345, p1361) reviews such a publication which claims that SBS is due to environmental factors. It is time that this false concept of SBS was laid to rest. (Occupational Health May 1995, p174)

Other Readers Write

Thanks to Dr Graham Sharpe who wrote from Wellington and enclosed some material about interesting developments in midwifery. Homeopathy is popular with midwives who use it during childbirth. Dr Sharpe also mentions a case known to him where a child died from a brain abscess due to a delay while homeopathic remedies were administered. The other case concerned a case of poisoning when a naturopathic remedy contained aconite. Aconite is severely toxic to the heart and this example shows why naturopathic remedies should be subject to the same restrictions and controls as other drugs.

Denis Dutton forwarded two articles as well. One from Annals of Internal Medicine (Vol 121, No.10) outlined the well-known complication of liver damage which can be caused by a wide variety of Chinese herbal treatments, in this case “Jin Bu Huan” tablets. The other article, entitled “Bitter Herbs: Mainstream, Magic, and Menace”, is an editorial from the same issue as the journal above.

The FDA managed to ban the use of Jin Bu Huan, but their job will be made more difficult by the Hatch bill. This is “The Dietary Supplement Health and Education Act of 1994” which was shepherded through the US Congress by the quack-apologist Senator Hatch. Its language is so imprecise as to be a triumph for the promoters of quackery everywhere. The editorial ends with a plea for doctors to spend more time with patients exploring the “human interactions that are central to the physician-patient relationship.”

Hoxsey Cancer Quackery

Soon after I returned home from our annual conference, Bernard Howard sent me a travel guide for patients planning to go to Mexico and gift their money to a pack of criminal fraudsters who know that the Hoxsey treatment is useless. As well as the airfares to the US, the Hoxsey clinic charges are US$1250-1600. Presumably this is to cover the costs of the “tonics” or as I call them, Kentucky fried medicine. As I explained at the conference, we know what these quack formulae contain and they could be made up in New Zealand for a few dollars.

MVA Insurance Fraud

Los Angeles is the capital for staged motor vehicle accidents (MVAs) where professional criminals, unscrupulous lawyers and doctors participate in phony insurance claims. Until I read about this I was aware of a problem with “whiplash” (also known as chronic remunerative neck injury), which has been a rich source of money for litigants. Phony claims fall into several groups: personal injury, claims for accidents that never happened or actual crashes involving unsuspecting drivers and staged accidents involving previously damaged vehicles. (Christchurch Press 24/7/95)

Faking It?

Vicki Hyde passed on to me a peculiar letter from a Dr Hussein of Jordan asking us to participate in research in the paranormal immunity of fakirs to pain. The letter is the usual mixture of pseudoscience. In fact, no individuals possess any “paranormal” immunity to pain, unless of course they are lucky enough to lack the spinothalamic tracts which carry pain messages to the brain.

Humans possess widely varying responses to pain stimuli which are subject to attenuation by cultural factors, conditioning and belief. Slowly rising pain stimuli can be centrally blocked. I have seen (and discouraged!) my daughter pushing needles through her finger. I reviewed the question of pain control in my paper on acupuncture which is available from our organisation.

Pseudo-medicine

This is a copy of a presentation given to the New Zealand Skeptics 1995 Conference in Auckland

When Denis Dutton asked me to prepare some comments on this topic he gave me a very wide brief covering, “any aspect that strikes your fancy”.

Since he has left the definition and the territory to me, I will indulge myself, knowing that any remark from here on will be controversial.

Over the same time I had the privilege to witness one of history’s recurrent twists, whereby there is a recapitulation of medical behavioural patterns which can be expressed in Darwinian terms. This has provided some of us with the opportunity to observe the consequences arising directly from the ebb and flow of irrational human behaviour.

In the late 1940s I set out to become an engineer, but I meandered into medicine. I retain some interests in the area of the physical sciences and I think I understand why a 747 flies and usually does not fall to bits on take-off or landing. Such deep insight allows me to perceive the distinction between the functioning of an aircraft engineer and that of a traditional doctor. It is mandatory, as well as reasonable, to test the wings of a proposed new aircraft to the point of destruction in an aeronautical laboratory. In most countries, similar destruction of a human being in a physical or psychological sense is forbidden, or at least not discussed openly in public.

The distinction between the two situations does not stop there. In the former instance, a physical object is being tested by engineers and scientists using a fairly soundly based set of facts, many of which will not change as knowledge evolves. However, errors can occur in both the design and testing of an aircraft wing due to the fallibility in human terms of scientists and engineers. Conversely, in the case of interactions between orthodox doctors and patients or clients, the interactions involve two sets of human behaviour. The nett effect is that at least in terms of ephemeral knowledge, there will be a much greater measure of certainty in the case of the aircraft wing testing than there will be in any health professional-patient interaction.

All that seems very obvious, but I can assure you it is not obvious to many who design and manage health services in various parts of the world, nor is it understood by many orthodox clinicians.

These considerations do, however, lead on to recognition of one perspective through which pseudo-medicine can be defined. In discussing pseudo-medicine we are really addressing a pattern of behaviour which is incongruent with principles common to sound aircraft engineering and sound allopathic medicine. Because a set of physically determined factors imposes a very firm set of disciplines upon the aircraft engineer, he or she operates within definable, and fairly closely defined, sets of constraints.

That is not the situation as far as medicine is concerned. An aircraft wing talks back to its designer by performing efficiently or failing. A patient or client exhibits an enormous range of responses to the propositions of a health professional, who operates within loose constraints, extremely wide boundaries and enormous levels of tolerance. Failure to observe what we may loosely term the laws of nature in relation to aircraft wings induces clearly observable and immediate consequences. Errors of logic and application of scientific knowledge or the indulgence of magic and quackery can persist for centuries in terms of medical practice.

My first point then is that the aircraft engineer is brought face-to-face with the realities of certainty and uncertainty from the outset. Such is not the case for health professional patient interactions.

Uncertainty

When confronted by uncertainty, a person who has a sound understanding of rationality and science acknowledges that doubt and ignorance are facts to be accepted and confronted. If we pause to think about that, hopefully a majority of us within medicine will rapidly realise that John Kenneth Gailbraith was correct when he said “when people are least sure, they are often most dogmatic”.

That idea can be extended by the observation that many who are superficially extremely confident suppress their doubts and uncertainties through extremely assertive behaviour and exposition of dogma. Sometimes they are exposed, as happened to Margaret Thatcher when caught on the hop by the BBC, who perceived she really did not know what to do about the political future of Hong Kong after 1997. “…now, when you say that, you don’t have to go into, to say, well now, precisely what is the nature of this link and the nature of the law and so on…”2

The problem with the Thatchers of this world is that during their predominant period of confidence, while they suppress any dangerous urge to admit doubt and uncertainty, they can inflict devastating damage on huge chunks of society and humanity generally. The consequences may be disastrous for many of us and not just for Argentinean sailors.

That arch sceptic, the late Petr Skrabanek, in a signed Lancet editorial entitled “The Epidemiology of Errors”, quoted Lewis Thomas: “A good deal of scientists, many of them in the professional fields of epidemiology and public health, have never learned how to avoid waffling when yes or no are not available, and the only correct answer is, I don’t know”.1 Pseudo-medicine arises when doctors, particularly, are confronted by a problem for which there is no clear-cut answer. Unfortunately in such situations, many doctors while swearing allegiance on the altar of medical science, move into the Thatcher mode. The practice of pseudo-medicine is based on that phenomenon.

Contrary to the viewpoint of a majority of the public and the media, and against the enthusiastic prophesy of many health professionals, areas of uncertainty are going to become more extensive rather than less as we move into the 21st Century. As technology becomes more sophisticated, complex issues concerning its application are going to raise increasing areas of uncertainty. It is not difficult to predict that there will be an increasing tendency for impetuous action to be taken as anxiety levels increase in the face of uncertainty.

Conversely, there may be a decline in recourse to consultation on the basis of “I don’t know, can you help?” Systematisation of doubt, and suppression of uncertainty lead to indulgence in such practices as homeopathy, chelation and a variety of magical and quack practises. I am not going to go into those areas in detail because they have been well traversed at previous annual meetings of this Society. Rather I want to spend the remaining time indicating the pervasiveness of the problem.

If we put aside the really major health disease problems of society based upon deprivation, economic inequality, hopelessness, loneliness and so forth, we are left with the impact upon society of the chronic degenerative diseases of bones, joints, the cardiovascular systems and cancers. These are the happy hunting grounds of pseudomedicine. The operation of total hip replacement has long since passed the equivalent of the testing of the 747 wings, and is now a standard procedure with sufficient experience behind it to make predictability of application to particular people reasonably certain. That does not mean that a host of other factors are not relevant to the decision whether, when and how to operate on a particular patient and to decide who pays to whom how much.

By contrast, the pain relief to be offered to the person on the increasingly lengthening waiting list for a hip operation provides a fertile ground for the exhibition of pseudo-medicine. Physicians like me do not have ideal pain relieving remedies available for prescribing to such patients. Chronic conditions wax and wane in intensity and it is very difficult to match the interplay of useful and dangerous effects of chronic pain management by drugs, against risks of death, disability and a host of economic factors.

The temptation is always there to indulge in the potentially legitimate use of placebo effect, maybe honestly at first with full understanding of what one is doing, and then to slip into the realm of magic. The boundary between rational therapy and pseudomedicine is very fine, and the width of that boundary varies considerably between one realm of therapy and another and between one doctor and another.

My concept of pseudo-medicine, therefore, is that doctors indulge in the practice when they stop saying, “I don’t know”, stop recognising uncertainty, and substitute false, self-deceiving action based on phoney certainty, backed by great enthusiasm and stern dogma. The euphemistic term “art of medicine” is then applied to this particular brand of practice. The words “art” and “medicine” are simultaneously debased.

Nihilism

Commencing early in the nineteenth century, what has been termed scientific and therapeutic nihilism developed initially in France. In the late 19th Century, influential figures from North America and England, including Sir William Osler who typified both environments, threw their weight behind the therapeutic nihilistic movement. This involved a sceptical approach to the practices and remedies of traditional medicine, and called for the application of rational study and controlled observation of the natural history of disease and its modification in various ways. There was considerable opposition to Osler. Rationalism, scepticism and the scientific method itself, are not immune to rigorous querying from a variety of viewpoints. All can be converted into new forms of religion and all are subject to phases in development.

It took about a hundred years for therapeutic nihilism to demolish significant sections of the old pharmacopoeia, continuing use of which was justified and dignified as being part of the art of medicine.

Earlier in the talk I referred to the interaction of two sets of behaviour when doctor meets patient. History is repeating itself at present as the boundaries where medical science and human behaviour meet are becoming a major topic in the more thoughtful pages of the New England Journal of Medicine, Lancet, BMJ and so forth. Interestingly, the predominant theme in this new wave of medical literature centres on the problems of uncertainty.

Jonathon Rees in the BMJ puts it this way. “For any activity dependent on new knowledge, as medicine is on science, the future is uncertain simply because new knowledge always changes the rules of the game. But even if we could dream this problem away, our guesses of the future will be in error because we continue to delude ourselves, outside the laboratory at least, that we understand the present…”3 Herein lies another basis for pseudo-medicine. Heath professionals like to feel confident and to project confidence in terms of their relationships with patients. Pseudo-medicine flourishes on the basis of apparent confidence exhibited by the professional. The stage is being set in my opinion for an increase in the practice of pseudo-medicine.

Anti-orthodoxy

During the 1960s, 70s and 80s there was a wave of revulsion directed against orthodox medicine and particularly to its perceived power. To some extent the evils attributed to the atomic scientists spilled over into public attitudes towards orthodox medicine. What was perceived as unholy power held by the medical profession was seen in terms of a citadel which should be destroyed. We saw the revival of naturalism, herbalism and a return to various magical procedures. One of the major textbooks of so-called holistic medicine claimed restoration of the theory of transmutation of the elements whereby sodium was converted to potassium by plants.

The attack was unconsciously, and by some cynical entrepreneurs consciously, directed at the whole concept of therapeutic nihilism. The wash from this revolution lapped on the thresholds of medical schools initially, and then penetrated the corridors of academic medicine. To the horror of people like me, graduates of our young School of Medicine began openly to practise homeopathy and chelation.

I analyse this situation as being due partly to the failure of us as educators to prepare students to handle the avalanche of evolving knowledge in the fields of biochemistry, molecular and behavioural medicine. We have been overwhelmed and have not known how to handle the situation. Our students have entered a world in which monetarism has gained the ascendancy and they see a desperate need to make a living. Those who choose not to become technocrats, replacing hips and removing cataracts, are the most vulnerable. Many of them have already succumbed. Moreover the ramparts of the citadel have been breached in more significant ways.

Our students face the usual mixture of myth and reality which typifies the real world — we have not prepared them adequately to confront this reality and provided them with teaching to handle the situation calmly and rationally.

There is a current vogue for insisting that doctors must model their approach to patients upon so-called “evidence-based” medical practice.4,5 The general concept implies that resources of the State, in particular, should only be expended in those areas where there is so-called objective proof that expenditure will significantly influence the natural course of a disease process. Impetus has been given to this movement through a failure of classical epidemiological approaches to produce clear-cut answers for handling the problems of middle and old age.

Over the past two to three decades, so-called scientific medicine backed by exhortations of academia has persisted in traversing the pathway so heavily criticised by Skrabanek and others. This trend has to some extent been driven by a need for resource acquisition for some sections of medical epidemiology. Disciplines such as cardiology have been happy to help create and then support a mirage through which scientific medicine is seen as responsible for releasing an accelerating series of miracles which will ultimately bring lifelong happiness to everyone. When confronted by the failure to deliver to the masses, sections of these same disciplines, like clinicians, have resorted to pseudo-science that dangerous ally of pseudo-medicine.

Rather than confronting politicians and the public with a clearly defined list of uncertainties, probabilities and areas of ignorance, as David Naylor from the Institute for Clinical Evaluated Sciences in Ontario has pointed out, they have “continued to produce inflated expectations of outcomes-oriented and evidence-based medicine.”5 Following these pathways, they have resorted, not to metaphysics or alchemy, but rather to meta-analysis and leaps of faith which are presented as scientific truths.

The Real Culprit

As Skrabenek has pointed out, the real culprit in all this is “risk-factor epidemiology”. This brash young infant amongst the medical sciences has continued to feed information and misinformation into the media. To quote Skrabenek again, “by the misuse of language and logic, observed associations are presented as causal links”. He further points out that “risk-factor epidemiology relies on case-control or cohort studies without rigorous standards of design, execution and interpretation, even though such studies are susceptible to at least 56 different biases. … How should one remedy this state of affairs — bigger studies, better measurement of risk factors, more complex statistics? Statistics are no cure for the faulty paradigm of risk-factor epidemiology.”1

It is in these areas that pseudo-science has aided and abetted what I perceive to be a particularly dangerous form of pseudo-medicine. It is in these areas that I perceive the most significant breaching of the ramparts of the citadel of scientifically based medical practice.

How has this come about? I believe it derives from the attributes of human behaviour stressed in the earlier part of this talk. Faced with failure to reach their objectives within a particular time span, many working in cardiovascular, cancer, and degenerative diseases have chosen to cope by denying areas of ignorance and uncertainty. Unfortunately they have gone further and have moved the goal-posts when it suited them. They have extrapolated, simplified and at times gone even further.

An obvious example to quote is the famous Lipid Research Clinics Study referred to in a paper at Palmerston North last year. In this study a somewhat unpleasant drug called cholestyramine was used to treat North American men held to be at particular risk from coronary artery disease due to elevated blood cholesterol levels. Extrapolation from that study was quite extraordinary and media manipulation of enormous magnitude was employed to preach a message intended for the masses when the facts were that such extrapolation was invalid for women and for the great bulk of the population.

You will all probably believe, correctly, that strict standards should apply to evaluation of both old and new therapies. It is a truism that anything short of randomised double-blind trials is regarded by proponents of evidence-based medicine as providing an unreliable base upon which to proceed. The problem is that these worthy objectives are being distorted and the public is not being given a transparent account of the problems.

Hormone Replacement

A classical example at the present time would be the largely male-determined dogma that hormone replacement therapy for post-menopausal women cannot be justified in terms of evidence-based medicine. The pseudo-medical pronouncements in this instance have a very complex background which is not usually presented. HRT in terms of scientific literature has concentrated almost wholly upon the fact that women after the change-in-life tend to catch up on men in terms of manifestations of atherosclerosis. There have been no published results from major double-blind prospective clinical trials of oestrogens alone or oestrogens combined with progesterones testing whether or not this therapy retards the appearance of myocardial infarction (coronary attacks) in post-menopausal women.

Prospective trials have shown that oestrogens make women more comfortable in terms of their nether regions, their skin texture and preservation of femininity itself. There is some soft evidence that osteoporosis may be retarded amongst woman taking HRT. Thus the pseudo-medicine proponents of evidence-based medicine who concentrate solely upon one aspect of hormone replacement, that of the cardiovascular effects, are not indulging in true science.

As Naylor has put it, we live in the era of chronic and expensive diseases. “Until the ongoing revolution in molecular biology pays more concrete dividends, we shall be muddling along with what Lewis Thomas characterised as half-way technologies. However medical muddling is a profitable business…”5 It is profitable for research groups, for industry and particularly for the exponents of pseudo-science and pseudo-medicine.

False Prophet

However it is more complicated than that. The general assumption by the practitioners of pseudo-medicine is that more, and what they term better, data will dispel uncertainty in medical decision making. Those who say these things seem unable to learn even from recent history. Those who put their faith in meta-analysis are following a false prophet. Take the case of magnesium in treatment of myocardial infarction. A meta-analysis published in 1993 is entitled “Intravenous magnesium in acute myocardial infarction. An effective, safe, simple and inexpensive intervention”.6 Two years later, results of another mega trial showed that magnesium was, if not totally ineffective, only minimally so in treatment of myocardial infarction.7 Resorting to big numbers will not necessarily solve problems from which the pseudo-medicine proponents are seeking to escape nor will it satisfy the absolutist neo-nihilists.

The current vogue for meta-analysis has arisen from a problem clearly recognised by both impeccable medical scientists and proponents of pseudo-medicine. This is the sheer cost of answering key questions based upon hypotheses propounded in relation to chronic diseases. Because genetic endowment heavily influences the differences between us, manipulation of the environment, including our internal environment, through drugs or diets will usually produce gains at the margin, which are usually minimal.

Blunderbuss therapy requires treating of the masses, many of whom will not benefit, while others are harmed by the proposals. The passion for evidence based medical practice, given our current range of technologies, must make recourse to fairly desperate measures. Thus meta-analysis has become big business. Like is not being lumped with like. Little lumps and big lumps of data are being gathered together by various groups beavering away upon the basis for their own particular perspectives, all seeking to justify their particular beliefs which are promulgated as gospel to an eagerly awaiting public. Unfortunately, some of the larger lumps so aggregated are themselves curate’s eggs.

A classic example is the so-called MRFIT data. The Multiple Risk Factor Intervention Trial (MRFIT)8 was a massive study mounted in North America, involving screening of either 361,662 or 361,629 men. Data from the MRFIT screenees has contributed very significantly to a number of the meta-analyses.

Werkö from the Swedish Council on Technology Assessment in Health Care has shown clearly that this massive body of data is significantly and seriously flawed.9 There is inconsistency between reports published in different journals simultaneously. The quality control of the basic data is uneven and people using the material seriously have not even bothered to check the relatively simple points investigated by Werkö. Not to do so is a form of scientific laziness, a form of pseudo-science. If these writers have done so and failed to spot the obvious flaws, then their baseline checks have been sloppy. If they have done so, and uncovered the same points as Werkö and chosen to ignore the evidence in front of them, they are true practitioners of pseudo-science and pseudo-medicine.

Meta-analysis has come in for hefty criticism and deservedly so. While its proponents acknowledge that it is a surrogate for the massively expensive prospective studies which are really required, they frequently go way beyond the capacity of the method in terms of the public pronouncements they make. In particular this applies to translation of conclusions relevant to people at special risk, to the advice given to the masses who may not share the same risks or who portray them in only a minor degree. Meta-analysis is now an art form whose scientific significance must be challenged at each stage and with each pronouncement.

Political Involvement

The situation is more sinister than that because politicians through their minions have cottoned on to the value of some of these manipulable analytical techniques. Thus, information gathered in relation to the National Health Service of the United Kingdom is being used to support claims of success of recent government policies. The same types of problem identified by Werkö arise when politicians make use of this type of data. Once politicians and media get into the business of using flawed information, or of distorting sound information for particular purposes, very unhealthy alliances will result.10,11

Our critics are correct in stating that medicine has built a very powerful base within society. Pronouncements by any segment of medicine or its associates are likely to be taken seriously, even in the face of the current wave of mounting scepticism. Epidemiologists and their allies in cardiology have established a major section of the health-disease industry. There are consequences. For instance, an increasing epidemic of osteoporosis in some western countries may well be based upon reduced calcium intake, particularly by women. Dairy products have been the main contributor of calcium in those countries. In contrast to big sections of epidemiology and cardiology, the dairy industry has employed competent nutritionists and made some attempt to keep pace with evolving knowledge of human nutrition. It deserves credit for the burgeoning range of modified milk products, all of which contain calcium. But the damage has been done from within the medical power base. As David Naylor has put it, these difficulties have arisen from the Malthusian growth of uncertainty when multiple technologies combine into clinical strategies and at the public advice level.5

Thoughtful critics of societal development have been drawing attention to these problems. Many advocate a solution through the information revolution, but in terms of the present topic they have failed to perceive that medical information is fragile, patchy and usually imperfect. Like the Lancet editor, I do not believe the consumer watchdog type of approach, with its challenge to the medical powerbase, is going to change the situation at any great speed.11

One healthy fallacy states that the medical powerbase rests solely on possession of scientific information and a monopoly thereof. As I have tried to demonstrate that base is neither secure nor constant. In the health-disease management industry, power does not reside in possession of scientific information. The current success of the inheritors of the old magic, that is the quack acupuncturists, the chelation therapists, many herbalists, naturopaths and so forth, does not reside in a possession of a body of scientific information or a monopoly of its use. This has always been so. Medical power rests as much on uncertainty as it does on technical expertise or possession of a particular body of ephemeral knowledge which will be disproved tomorrow. How can that be so?

The Lancet states it thus, “uncertainty in the face of disease and death fosters a compelling need for patients to trust someone — and a reciprocal authority among doctors. A leap of faith will always be needed. Information does not, and cannot provide all the answers.”11 We thus have a paradox to confront.

Pragmatic Doctors

To return to the aeronautical engineer. Doctors must indeed make decisions, give advice and offer assistance based on limited interpretation of limited evidence. For the foreseeable future doctors must make decisions which will not be derived from carefully controlled prospective randomised clinical trials. They must nevertheless try to make valid decisions. They cannot indulge in the luxury of being inactive in the face of an absence of evidence. That privileged position belongs to the lawyers, the philosophers and the ethicists. In the end doctors have to be pragmatists. Clinical decisions must be made through a plurality of means, each of which must however, undergo “profound interpretative scrutiny”.4

The doctor’s role is more difficult than that of the aircraft wing designer. They must discipline themselves continually to apply medical knowledge in conjunction with their experience and that of their colleagues. “The unifying science of medicine is an inclusive science of interpretation.”4 The black and white situation of 747 wing testing does not occur in medicine. “Medicine is a series of grey zones in which the evidence concerning risk-benefit ratios of competing clinical options is incomplete or contradictory.”5 The grey zones have varying boundaries which change rapidly.

We academics have great difficulty enabling undergraduates and emerging graduates to cope with these phenomena. It is not surprising that many move into pseudo-medicine. It is not surprising that the teaching of orthopaedics is always much more popular with undergraduates than that of clinical medicine. Once again to quote Naylor, “clinical medicine seems to consist of a few things we know, a few things we think we know (but probably don’t) and lots of things we don’t know at all”.5

We academics have to cope with the fact that when evidence alone cannot guide clinical actions, some undergraduates will take up a minimalistic approach whereas others will favour intervention based upon varying balances of inference and experiences and others will turn to pseudo-medicine. Our job as academics is to make emerging clinicians comfortable with a system whereby they can make decisions under conditions of uncertainty.

Over the next decade at least, I believe medical academics will have to confront a somewhat irrational passion for evidence-based medicine and meta-analysis, and we must teach that there are limits to medical evidence and its application. The craft of caring for patients is a legitimate, scientifically appropriate adjunct to medicine. That role is necessary for the comfort and sanity of human society. Osler said, “good clinical medicine will always blend the art of uncertainty with the science of probability.” We need to understand, then to explain what we mean by the term probability.

I shall end with another example. The practice of pseudo-medicine can inflict much discomfort. For instance, young doctors and nurses have considerable difficulty in agreeing to decisions that this patient or that should not be subjected to the indignity of resuscitation procedures, but rather be left to die in peace.

There is a significant and coherent literature indicating that a majority of resuscitation procedures as undertaken in the 1970s and 80s were futile from the outset. The continued pseudo-medical practice in this regard has led to a situation where relatives expect resuscitation procedures to be undertaken. Their concept of power sharing puts heavy pressure on younger doctors to overturn non-resuscitation orders. If the younger doctors submit, an undignified charade ensues. In turn, that situation has created an environment in which aspects of the so-called passive euthanasia debate have become more tangled than was necessary.

I will not dwell further on that point. Rather, I wish to end by emphasising that facing up to uncertainty and accepting areas of ignorance honestly, does not constitute an admission of laziness or incompetence. That, however, is the perspective which sections of the legal profession and society generally are promoting at the present time. If we submit to such pressures and false perspectives we shall end up as we did in relation to the false-confession mistaken-conviction situation, which was discussed at our conference last year.

All professional groups are vulnerable to external influences playing on our own emotional state and anxiety level. Pseudo-medicine thrives in this environment. If we take the subject of evidence in a legal sense we can remind ourselves that a series of techniques have been advised to law authorities over the past century and a number are still in use in the United States, including the polygraph. All have proved to be potentially unreliable, subject to manipulation and all can produce false-positive and false-negative results. If anything their use increases the risk of false confessions.

Those members of the medical and psychology professions whose weakness and pseudo-science has contributed to the situation have much to answer for. Faced with such examples we should have a better understanding of the pervasiveness of the problems of pseudo-medicine and pseudo-science.12 Society needs the NZCSICOP.

Green Peppers

I shall end with the parable of the green peppers. One could term it a parody. The original publication is in the Journal of Irreproducible Results somewhere round about 1955, I think, but I have lost the reference. Some bright workers in Chicago noted that everyone who had eaten green peppers in their youth but had reached the age of 89, had grey hair or white, rotten joints, few teeth, failing eyesight and poor hearing. The main reference in the bibliography was to a guy called Shakespeare somewhere in the early 17th Century. The green pepper eating cohort who had reached the age of 105 were considerably worse off. No-one who had eaten green peppers was alive by the age of 130.

The green pepper industry obviously faltered at that point. However, a subsequent paper which I believe was written but rejected by the same worthy journal, described a restudy of the situation. This showed that people who had eaten green peppers when surveyed at the age of 20 had normal hearing, all their teeth, no lens opacities and sound joints.

In comparison with the older cohorts studied in the first publication, those who had eaten green peppers ten to twenty years earlier showed a mortality rate of 0.05%. Amongst the 90 year old group in the earlier paper, the mortality experienced by that cohort was noted to be 95.2%. Of high significance statistically was the observation that amongst people in that population over the age of 100, only 1% consumed green peppers in the last twenty years. The conclusion was obvious that those who stopped eating green peppers after an interval of twenty years suffered greying and falling of hair, diminished eyesight, reduced hearing, loss of teeth, a very high mortality rate and rotten joints.

Evidence is one thing, quality of evidence another. Intelligent interpretation and carefully planned application of evidence belong to different dimensions. Quality of action based on evidence depends upon the quality of the evidence, its completeness or otherwise, and the quality of the interpretation plus recognition of what is not known and what is not likely to be known over the next years or decades. Life was not meant to be easy.

The practice of medicine combines the twin problems and pleasures inherent in basing action upon adequate evidence on the one hand and inadequate evidence on the other. Practice of the art of medicine is a legitimate activity dependent for its integrity upon the understanding of the dilemmas posed by this dual basis for action and understanding of the nature of science, including the ephemeral nature of scientific knowledge. Pseudo-medicine is practised by those who lack the resolve and energy to face this intellectual challenge.

References

1) Skrabanek P. Lancet 1993; Vol 342: 1502

2) Margaret Thatcher, PM. BBC World Service interview, 1 Nov 1983

3) Rees J. BMJ; Vol 310: 850-853

4) Horton R. Lancet 1995; Vol 346: 3

5) Naylor ED. Lancet 1995; Vol 345: 840-842

6) Yusuf S et al. Circulation 1993; Vol 87: 2043-2046

7) ISSIS-4 etc. Lancet 1995; Vol 345: 669-685

8) MRFIT. JAMA 1982; Vol 248: 1465-1477

9) Werk[oumlaut] L. J. Int. Med 1995; Vol 237: 507-518

10) Wright M. GP Weekly 1995; 2 August: 12-13

11) Lancet 1995; Vol 345: 1449-1450

12) Lancet 1994; Vol 344: 1447-1450

Is Counselling Useful?

Surprising results from a US study of the effectiveness of counselling on reducing juvenile crime.

In the March NZ Skeptic, Dr John Welch’s excellent column mentioned an article in the British Medical Journal (BMJ) about a social experiment which started in 1939. I have not seen the BMJ article but it can only refer to the Cambridge-Somerville experiment. Not just because this was the only such study started in 1939, but it is still (to the best of my knowledge) the only large-scale, long-term study on the effects of counselling which can reasonably be regarded as good science.

It is worth looking at this famous experiment in a little more detail. The instigator was the Harvard Professor of Medicine and Social Ethics. The subjects were boys between the age of five and 13 thought to be “at risk” of juvenile delinquency. It was proposed that a programme be started to prevent these boys becoming delinquent. It would involve “all the aid that a resourceful counsellor could possibly give, backed by the school and community agencies”.

In fact it eventually involved churches, scouts, YMCA, and summer camps plus, where necessary, medical and psychiatric treatment. The counsellors were particularly concerned to involve the families of the boys and this was done whenever possible. The treatment programme was intensive and lengthy; on average it lasted five years — a considerable time in the life of a child.

Professor Cabot (who died in the year the project started), while convinced the programme would be valuable, was concerned that it should be properly assessed. Thus the boys were grouped into 325 matched pairs, each pair being similar in age, background, etc. One of each pair was randomly assigned to the treatment group, the other to the control. It is because of this that it was possible to decide “Did the treatment help?”.

Major papers on this study were published in 1949 and 1951 and the final paper, by Dr Joan McCord, was published in 1978. Some 253 of the matched pairs had completed the programme and 30 years after the project started, Dr McCord was able to locate 480 of the men involved.

About half of these were from the treatment group, and about two thirds of them felt the project had been helpful and improved their lives. Most had fond memories of their counsellors.

Dr Welch writes that the BMJ article found the treatment group to be “sicker, drunker, poorer and more criminal”. This is true but I think it important to note the individual differences were very small.

The project was started to prevent juvenile crime. Of the treatment group, 72 had a juvenile criminal record, compared with 67 from the control group. This is a very slight difference, but clearly the project failed in its main aim which was to prevent juvenile delinquency.

Similarly, 49 of the treatment group had been involved in serious adult crime, compared with 42 of the control group. Again a very slight difference. For factors such as recidivism, alcoholism, stress-related illness, and job satisfaction the pattern was similar. That is, the control group did better than those who were treated — but only by a very small amount.

In only one important way was the treatment group better — minor adult crime. But again the difference was very slight: 119 of the treatment group had minor criminal records, compared with 126 for the control group.

It is true, however, that taken together the differences between the two groups were found to be statistically significant. The treated group had been harmed by the treatment, although the harm was minimal and would not have been revealed by a small-scale study.

There are several major lessons for skeptics here. Firstly, all treatments should be properly assessed and that means using a control group (obviously in this kind of treatment “blind” studies are not possible). How much money (taxpayers’ money) is being spent in New Zealand on counselling? Is the money well spent? Is any attempt being made to assess the value of the treatment?

Secondly, the natural and powerful objections to such assessments must be resisted. The idea of using a control group horrifies many people — “But these people are being used in an experiment! They are not being treated!” Such objections assume we already know the treatment works. But we do not know this and our intuition may be completely wrong.

Thirdly, people are incapable of objectively assessing their own treatment. That is why testimonials to the healing power of any treatment are completely worthless.

Fourthly, non-intervention may be the best treatment. The problem is that it is the hardest to apply because there are powerful forces mobilised against it. The patient welcomes treatment (just how neglected did those boys in the control group feel?) and the professional wants to help.

Counselling is getting to be a major industry in New Zealand but its value should be questioned. All such professionals should adopt the motto “First do no harm”, but until proper assessments are made, how do they know whether they are doing harm or good?

Pseudoscience and the Midwife

Recent issues of the Skeptic have contained expressions of puzzlement at some subjects being taught to tertiary students in New Zealand. The worst example is the Degree in Naturopathy planned for Aoraki Polytechnic. But is this really all that surprising?

Currently, health courses in polytechnics are including all manner of “alternative” medicine instruction as part of core courses. In my experience, the worst offenders are courses in midwifery.

Most midwives in New Zealand train for one year at a polytechnic, having previously completed a three-year course in nursing. There are three-year direct entry courses, but these are quite new and their first students have not yet graduated.

I teach anaesthetics in the one-year course at Wellington. The time allocated to me is one hour. The senior tutor also teaches this topic for one hour, a total of only two hours’ formal instruction in the whole course.

How relevant is anaesthetics to midwifery? I agree that the amount of knowledge needed by a midwife in this area is limited, but it is not generally recognised just how dangerous anaesthesia can be in the pregnant female. General anaesthesia is the third or fourth commonest cause of death in labouring women in the developed world. The situation is worse in Japan, where it ranks first or second. (The “or” is included because figures change from year to year. The United States has pushed anaesthesia down a slot as a cause of death in pregnant women by bringing gunshot into the top three.)

The point I am hoping to make is that anaesthesia can have a major impact in obstetrics, and I, for one, think that anyone involved in the care of pregnant women should have a sound background in the principles of anaesthesia, and why it can be so dangerous.

So is two hours enough? An open question, but homeopathy gets more than twice as much formal teaching time, and I assume the tutors are paid out of taxpayers’ money and student fees.

Midwives as a group seem to have a fascination with homeopathy. When challenged, defences range from “scientific proof” to “patient choice”. I will disregard the first of these, except to say that I have yet to be offered science or proof in any discussion of homeopathy with a midwife. (As an aside, the weakest defence I have heard is that the Queen is interested in homeopathy, so there must be something in it. These days, one would have thought that royal patronage of anything was guaranteed to ensure its failure, but I digress.)

“Patient choice” is fast becoming the defence of scoundrels. Should patient choice be the final arbiter in medical practice? It is a nice, politically correct idea, but choice is limited to what is realistically available. To defend the inclusion of something in a professional curriculum purely because the students or the patients are interested in it is lacking in sense and responsibility. I would guess that midwifery students might also be interested in skiing and wine tasting, and their potential patients may express an interest in Fascism or safe-breaking. Following along the lines of “choice” may lead to a more entertaining course, but would it advance the care of mothers and babies?

The whole question of choice leads onto the matter of informed consent. Does a midwife who uses homeopathy fully inform her patient (sorry, sorry; I should say her “client”) that she is using something that is unrecognised as a form of scientifically proven medicine, and that its use may put the patient (“client”; there I go again) beyond compensation by ACC should something go seriously wrong? Like hell she does.

Homeopathy is not the only intruder of its type in midwifery. Acupuncture is praised not only for its analgesia, but also as a means of inducing labour, stopping early labour, and turning breech babies the right way up before delivery. Aromatherapy has its advocates, and I have attended a labouring mother whose midwife insisted on having a lighted candle in the room as part of her client’s care. (Delivery rooms are oxygen-enriched environments, and she was not happy when I refused to proceed until the flame was extinguished. The hospital fire officer was even less impressed when I referred the matter to him.)

I was horrified recently to hear of the advice offered to the wife of one of my junior colleagues. She is expecting her second baby, and the baby has turned breech — i.e. bum first instead of head first. A midwife told her that she should lie flat on her back with her feet up until she felt dizzy and breathless, then walk around for a while. This was to be repeated several times a day, and would turn the baby back to present in the proper manner.

Anyone with the slightest knowledge of the physiology of pregnancy should know that if the mother is becoming breathless and dizzy, the baby is likely to be in an even worse state. In late pregnancy, lying flat can pose a significant risk to mother and baby, as the weight of the uterus can press on the aorta, reducing the blood supply to the placenta, and also on the vena cava, reducing the blood flow back to the mother’s heart.

Needless to say, the advice was ignored and the prospective parents are due to see a consultant obstetrician.

Pseudoscience is alive and well in the midwifery world, and is being taught to midwifery students.

Hokum Locum

ACC Decisions

The recent decision to award compensation to a lawyer who suffered depression because his bank loan was turned down is but one example of increasingly bizarre decisions by the ACC (Anything-goes Compensation Corporation). Money has also been paid out to victims for “memories” of childhood sexual abuse but in one recent case the alleged offender was aquitted and we are still waiting to see whether ACC will ask for their money back. (see Skeptic 34).

I obtained information about a court judgement involving ACC who awarded compensation to an employee of the Fire Service, one of a number of people affected by mass hysteria after the ICI Chemical Fire. Advising doctors said that his condition was not considered to be due to chemical exposure but his emotional state could be attributed to some stress surrounding attendance at the fire. The judge had no alternative under current law to do anything other than award full rights to compensation.

Not only do these decisions show a lack of common sense, they also illustrate what happens when no one is prepared to stand up and resist such claimants, who will continue to come forward as long as there is money available. This prevailing community belief that everyone is entitled to compensation for their “pain” whatever it is, is not limited to New Zealand. There is a worldwide growth in anti-medical science groups with self-denied psychiatric conditions. In the UK a sufferer from chronic fatigue syndrome (see Skeptic 21, 26) was awarded compensation because the stress of a car accident in which he received no physical injuries, made his symptoms worse!

Hoxsey Cancer Quackery

Bruno Lawrence recently went public with the fact that he is suffering from lung cancer and plans to make a TV documentary about his treatment at a Hoxsey Clinic in Mexico. About the same time, a syndicated article appeared in my local paper with the news that a Tauranga herbalist intended setting up such a clinic and applying to the local area health board for approval.

Hoxsey (1901-1973) developed a secret recipe of herbs and spices which he used to treat cancer patients. This followed an observation that a horse with cancer cured itself by grazing on certain plants. Hoxsey fought prolonged court battles with both the American Medical Association (AMA) and the FDA before taking his quack therapy to unregulated Mexico. He died from cancer despite self-treatment with his quack remedy.

His original nurse, Mildred Nelson, was still administering this quackery as recently as 1988. The American Cancer Society (ACS) has extensively investigated Hoxsey’s cancer quackery and I quote from the last paragraph of their report which I am happy to supply free to any reader as long as you send a stamped SAE: “In summary, the Hoxsey medicines for cancer have been extensively tested and found to be both useless and archaic. The ACS does not recommend their use by cancer patients.”

Quackery often follows a pattern as follows:

  • An apparently profound observation or emotional experience — in Hoxsey’s case, a sick horse, and in the case of iridology certain patterns in the iris of a sick bird. Doctors often revert to quackery following either job stress or a seemingly profound success with a new treatment such as acupuncture, homeopathy etc. (usually a placebo response).
  • An element of paranoia is useful, because this heightens the belief of the quack that the particular treatment is valuable and “everyone’s out to get me!” and leads to…
  • Conspiracy theory. In the case of Hoxsey, he developed the theme that doctors and the AMA had cornered the cancer market (is there one?). This is a very useful strategy for discrediting conventional medicine.
  • The quack remedy should be completely safe and quite expensive because patients will show improvement in proportion to money spent. Distilled water is cheaper and more convenient than homeopathic remedies and is already an accepted consumer fraud.
  • Reliance solely on testimonials and strict avoidance of clinical trials or any form of testing of the quack remedy. Testimonials are personal, entertaining and are excellent advertising, unlike the prosaic clinical trial which will show that the quack remedy is for the ducks. If a clinical trial or, in the case of Milan Brych, a court case, proves quackery, then all is not lost. Off-shore operations will ensure patients keep on coming, which is what hundreds of people did even after Brych was shown to be a complete fraud and actually in prison at the time he claimed to be at medical school. (I can think of a few doctors I would like to see in prison but that’s another story.)

Finally, the above information is subject to intellectual property rights and I expect a commission from any readers who set up successful cancer quackery clinics.

Psychopathology

An article in the BMJ (Vol 309 p883, “The dangers of good intentions”) caught my eye, as it is a devastating example of the psychopathology so evident in the helping professions. In 1939, 700 delinquents were randomly assigned to either a treatment group or a control group who received no treatment but were followed up 30 years later.

The treatment group received counselling, home help and other community assistance. After 30 years it was the treatment group who were sicker, drunker, poorer and more criminal! This shows that nothing can be taken for granted when trying to influence people’s behaviour, and often such programs create dependency. Our own welfare state is a classic illustration of this problem.

Psychobabble revisited

In Skeptic 33 I made a plea for hard data on the popular new condition of post-traumatic stress disorder (PTSD). Like any alleged medical condition it must be refutable, ie. capable of being proved wrong. A writer in the BMJ (Vol 309 p873) sharply criticised a case presentation on PTSD in a patient who was a heavy drinker. He pointed out that 40% of all patients diagnosed as having PTSD drink heavily and their symptoms (frightening ideas, nightmares) subside when they abstain. I am still cynically waiting to find out whether PTSD is described in populations which do not have compensation.

In Canada, a man was aquitted of stabbing to death his parents-in-law because a psychiatrist testified that the man was sleep-walking and therefore had not been responsible for his actions. The fact that the accused was also a gambler who had been caught embezzling money did not seem to be quite so important to the court!

Psychiatry as a specialty relies on rather soft science, and some psychiatrists are guilty of the most absurd psychobabble — eg, “Continuing success will reflect [the patient’s] ongoing committment to healing the wounded child within, which is the result of the experience of the poisonous pedagogy.”

Doctors’ signatures can certainly be very valuable. As far as patients are concerned, it means another ten paid weeks off work. Some 85,000 people have been collecting such benefits for more than one year and ACC is hoping to save $400 million by referring all cases to an independent medical panel.(GP Weekly, 22 Feb 95)

In the Australian Capital Territory (ACT) a new law allows people to use cannabis on a doctor’s prescription provided that the doctor keeps “research notes.” The ACT Health Minister described the new law as a “radical drug experiment”. I describe it as radical stupidity, as there is no evidence that cannabis is useful for the conditions proposed and I doubt the ability of individual GPs to conduct research. Here is my prediction: patients will flock to certain doctors who have found by research that their signature on a piece of paper is of considerable benefit to both the patient and the doctor’s bank manager. Buy ACT cannabis futures now! (GP Weekly, 22 Feb 95)

In the UK, a housing authority allowed preferential allocation for housing on receipt of a note from the doctor outling health reasons. However, they were able to revert to their normal process of allocation because everyone on the list had a note from their GP! All processes such as this become debased and degraded when subject to abuse.

Eau Dear!

Along with other legitimised quackery, the French government recognises a stay at a spa as a legitimate medical treatment. The National Audit Court pointed out that not only is there no proven scientific justification for spa treatment, but many carry bacterial health risks. Some spas have even been adding tap water to their natural mineral waters.

I seem to remember an investigation in New Zealand showing that certain “mineral waters” were indistinguishable from tap water. (New Scientist, 28 Jan 95)

Alternative Medical Remedies

The Medicines Act is being re-written, and already quacks are whining that the costs of licensing their remedies could force them off the market. Quacks also fear a ban on advertising that they can offer relief from various conditions. I don’t see any problem with the proposed law changes, as herbal remedies should come up to set standards of quality and safety and any claims of efficacy should be tested in randomised trials. (GP Weekly, 14/9/94)

After reading this I was intrigued to find a letter in the Lancet (Vol 344 p134) which looked at the ginseng composition of 50 commercial ginseng products. The authors found that 44 preparations ranged from 1.9% to 9.0% of ginsenosides, the active components. The remaining 6 preparations contained no ginsenosides at all. They also quoted a case of an athlete who failed a drug test. He thought he was only taking ginseng, but not only did his preparation not contain any ginseng, it consisted mainly of the banned performance-enhancing drug ephedrine.

Would anybody buy an aspirin that might contain either no aspirin at all or anywhere from 100mg to 500mg of the active drug? The authors conclude that “quality control is urgently needed for natural remedies with suspected or assumed biological activity.” I see a compelling case for continuing with a robust overhaul of our Medicines Act.

Face Lifts and Hair Growth

A Wellington plastic surgeon was critical of a recent proposal that GP’s could learn to do chemical face peels after watching a training video (Dominion, 15/9/94). GPs can buy a kit which contains enough chemicals and equipment to make a profit of $380 per patient for half an hour’s work. The process involves using glycolic acid to induce peeling and, by an unspecified process, cosmetic improvement. Just the thing for boosting the flagging profits of any North Shore Auckland medical practice where there are already so many doctors the place is in danger of turning into a ghetto.

I don’t intend watching the video, but the thought had crossed my mind that I could treat my vain patients in our RNZAF electroplating bay. A short dip in something caustic would give anyone’s face a good lift (off) or how about dermabrasion with a wire brush from the metal shop?

A much safer money-earning prospect is the exciting new treatment of electrotrichogenesis for bald men. I hope our editor can reproduce the advertisement which shows a futuristic looking chair with a hood poised to administer rejuvenating current to the recalcitrant scalp. [Unfortunately it’s a bit too dark to reproduce well — but it looks fascinating…]

Why not fill the waiting room with these chairs and invite balding males to pay for treatment while they wait to see the doctor on other matters. Even more doctors will be able to afford to go into practice on the North Shore!