Waiting for the big one

If the beliefs of a sizeable number of people turn out to be correct, this will be the final issue of the NZ Skeptic. According to a survey of 16,262 people in 21 countries conducted by market research company Ipsos for Reuters News, two percent of respondents strongly agree, and eight percent somewhat agree, with the proposition that 21 December 2012, the end of the current cycle of the Mayan Long Count calendar, marks the end of the world. Perhaps surprisingly agreement is highest in China (20 percent), while the Germans and Indonesians (four percent) are relatively dubious. One could perhaps question the representativeness of the sample (comprised of people who have agreed to take part in online surveys), but there must be a lot of people out there who are really worried about this.

David Morrison, who runs the Ask an Astrobiologist page on NASA’s website, was reported in Canada’s National Post (28 September) as saying he has been flooded with thousands of questions about the issue, with at least one a week from teenagers so concerned that they’re considering suicide. “The one thing in common with all of these scare stories about December 2012 is that they have absolutely zero basis in fact,” he said. “There was no Mayan prediction of anything going wrong, there’s no planet Nibiru, there’s no planet alignment, there’s no change in the Earth’s axis, there’s no change in anything about the Earth. It’s just a complete fantasy.”

Belief in impending apocalypse has long been a feature of certain religious groups, but the various 2012 scenarios have a distinctly secular flavour. There seems to be something deeply and paradoxically appealing about the notion that we will all be wiped off the face of the Earth, and it’s not all driven by religion. Some see it as a response to the uncertainties of life, providing a sense of narrative amid the chaos. Another factor may be that, at least in its secular incarnations, it derives from a sense of insignificance in the face of the immensity of deep time. The universe is more than 13 billion years old, life has existed on Earth for at least three and a half billion years, and we probably have another five billion years before the sun runs out of fuel. Against that, what is the value of a single human life? (That’s a question I believe can be answered, but space precludes discussion of it here.)

If Doomsday is almost here, at least it means that we don’t have to face the idea of life going on without us. Some, perhaps, would see our lives today as having more meaning if all of history was leading up to this moment, and there won’t be any more to come. We would become the heroes of the Story of Life – that story may be a tragedy, but at least we were in at the end.

The (bad) science behind the MMR hoax

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Who needs evidence, hey?

References

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

Irrationality waxes once again

There are times when the world seems to run along quietly from day to day, with very little happening. Then there are times like these. There are the ongoing aftershocks in Christchurch, many of them big enough in their own right to qualify as major quakes at any other time. There was the far larger earthquake in Japan, with its ensuing slow-motion nuclear disaster. There are wars and revolutions across the Middle East and North Africa which seem set to transform the politics of those regions. Millennial anxieties are on the rise once more.

It’s only to be expected at such times that irrationality should flourish. When natural disasters strike at random, many have a desperate need to seek some kind of pattern, or cause. Hence the attention given to Ken Ring’s claim to have used phases of the moon and solar activity to predict the Christchurch quakes – if the experts can’t say when earthquakes will strike (though the general pattern of aftershocks has actually followed GNS’s forecasts quite well) then there is a niche for those who claim they can. Many skeptical bloggers (eg Peter Griffin, Matthew Dentith, Alison Campbell, Darcy Cowan and particularly the Silly Beliefs team) have dealt with Ring’s claims; we add our five cents’ worth later in this issue.

Meanwhile in the US, many commenters on internet forums are putting the Japan earthquake down to karma for Pearl Harbour. Also in that country self-proclaimed prophet Harold Camping is raising quite a stir with his calculation that the Rapture will occur on May 21 this year – 19 months before the 2012 buffs’ choice for the Big Day. Camping says of the current upheavals: “There are still people that God has to save, and he uses them to get them to cry out for his mercy.”

There’s not much sign of that happening yet in Christchurch, where the citizens are more intent on helping themselves and each other, rather than seeking divine assistance. Slowly the city is getting back on its feet, despite ongoing tremors; life is returning. A small sign of that is that the NZ Skeptics annual conference will once again be held there, from 26 to 28 August. Register with the form mailed out with this issue, or do it on-line at www.skeptics.org.nz

Christchurch always seems to have had more than its share of Skeptics, many of whom have been seriously affected by the quakes. It will be good for us to get together once again, to share the strength of our usually far-flung community.

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

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

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

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

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

I shall:

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

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

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

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

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

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

1982: Professor Green retired.

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

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

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

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

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

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

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

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

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

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

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

The 1984 paper

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

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

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

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

Treatment

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

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

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

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

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

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

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

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

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

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

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

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

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

Unethical: Not in accordance with these principles.

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

Convention is a general agreement or consent. (OED)

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

His protocol did not deny women treatment.

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

He didn’t do that.

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

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

Why do manifestly false beliefs persist over time?

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

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

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

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

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

Treatment with curative intent was not defined in the abstract.

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

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

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

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

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

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

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

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

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

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

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

References

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

Forum

Non-custodial sentence inappropriate

In delivering a non-custodial sentence in the Janet Moses makutu case, Justice Simon France noted that expert witnesses considered the perpetrators were not acting out any customary cultural or religious practice. The appropriateness of a non-custodial sentence for manslaughter has been rightly questioned. Of additional concern, however, is that a golden opportunity appears to have been missed to condemn the very idea of makutu, that someone can be possessed by an evil entity necessitating a special curse-lifting ceremony or exorcism. Exorcisms, of course, are not confined to Maori culture.

Surely the time is long overdue for totally discarding all such outmoded notions of a pre-scientific age, and in particular makutu itself given that it can engender barbaric practices and lead to tragic consequences. Justice France has been reported as even expressing the view “Makutu did not kill her. She drowned”, seemingly completely overlooking the fact that it was an insane belief in makutu that generated all that followed.

Hokum Locum

Liquor still quicker

There is little doubt there are criminals who are prepared to drug women in order to sexually assault them. History records the commonest drug used was chloral hydrate in an alcoholic drink (Mickey Finn). The modern equivalent is rohypnol, a drug discontinued in New Zealand owing to its abuse potential. However, as Ogden Nash observed “liquor is quicker” and alcohol remains the most likely cause of incapacity leading to unwanted sexual activity.

There has been recent publicity alleging ‘drink spiking’ but a remarkable dearth of evidence to support these allegations. Invoking the law of parsimony, if women drink a lot of alcohol it is more likely that they were drunk rather than drugged by some additional chemical. This has been my experience in clinical practice. I was working in a hospital emergency department and a woman brought in her daughter who alleged she had been drugged during an evening out. They requested a blood test. I ordered a drug screen as well as an alcohol level. The time was 3pm the day after her night out. The drug screen was negative; however, the young woman’s blood alcohol was still 112 mg/100ml blood. The legal limit for driving is 80mg/100ml blood. I leave it to readers to do the maths but I suggest she must have been seriously intoxicated the night before!

The current hysteria about ‘date rape’ is a smoke screen to cover up serious alcohol abuse by many young people.

From the Journals

Bromelain, an aqueous extract of the pineapple plant, is widely sold as a natural organic anti-inflammatory agent. The results of a randomised controlled trial cast doubt on claims that it is an effective treatment for osteoarthritis. Although the trial was too small to be definitive, there was no benefit over placebo (Quarterly Journal of Medicine 2006, 99: 841-50).

High blood pressure features in a randomised controlled trial of acupuncture appropriately named SHARP (Stop Hypertension with the Acupuncture Research Program). Despite the promise suggested by case reports and small observational studies, active acupuncture was no better than invasive sham acupuncture at reducing systolic or diastolic blood pressure in 192 patients with untreated blood pressure (Hypertension 2006, 48: 838-45).

A New Zealand doctor has been given a grant of $5000 to continue her research into the treatment of autism. Her alternative methods involve dietary manipulations. In one case, “within a week of having colours and preservatives removed from his diet”, Dr Gullible (not her real name) claimed the subject had a vocabulary of 200 words. Well then, within a few more months he will have conquered the Concise Oxford Dictionary! Dietary manipulations involve a change in management and attention and it is this which is responsible for any observed improvements. These are placebo interventions (NZ Doctor, 15 November 2005).

Fat Lazy Teenagers

Claims have been made that overweight adolescents should have surgery. Some of these fatties have weighed in at 150-200kg. They can be seen in any shopping mall, usually eating a bag of chips and clutching a bottle of soft drink. The parents, usually the mother, are also obese and the situation is not a disease but one of child abuse. The standard of reporting and medical insight is pitiful. A report in the Christchurch Press (23-24 December, 2006) claimed that a possible cause of obesity was hyperinsulinaemia, an excessive production of insulin. Obese people who develop diabetes do have hyperinsulinaemia but this is caused by their obesity, not the other way round. The obesity causes an insulin resistance at the cellular level and the pancreas responds by cranking up its production of insulin.

After surgery, one teenager lost 80kg and is now training to be a chef! I think there needs to be a great deal more informed debate before the health system starts funding this sort of surgery.

Occupational Health-Disease of the month

The history of occupational medicine is full of examples of absurd complaints being linked to the workplace. For example, pain syndromes in women who are only typing a few words per minute (refer Dr Yolande Lucire’s book: RSI Belief and Desire).

The latest medical construct is ‘acoustic shock’ seen in call centre workers. Seven hundred employees have reached out-of-court settlements in the UK with a payout of three million pounds. A further 300 cases are pending. It pays to have an employer with deep pockets. An article in the Guardian Weekly (24 November, 2006) advises that “acoustic shock is caused by exposure to a sudden increase in noise, but people who are already anxious or under stress appear to be particularly prone to it.”

Note the careful wording. The ‘disease’ is not created in normal people but in those who are naturally “anxious or under stress”. These words are designed to obscure the fact that this is not an occupational disease but an attempt to attribute personal angst to the workplace.

Although not given to crystal ball gazing, I predict that this condition will next appear in Australia closely followed by New Zealand. Furthermore, I predict that the condition will remain unheard of in India, the origin of most call centre calls, since there is no compensation available.

The next time you are disturbed by a call centre while eating dinner, yell loudly down the phone and tell the caller to make a claim for ‘acoustic shock’.

Sickie Busters

Fraudulent absenteeism is just as common across the Tasman as it is here. Absenteeism costs Australian industries an estimated $7 billion dollars per year. Rates are around 3.5 percent but this figure can double with-you guessed it-call centres! These must be the people who are away from work while consulting their advisors about their claim for ‘acoustic shock’.

Some savvy people have set up a business (Direct Health Solutions) and they check up on people taking a sickie. Client absenteeism has been reduced by one third and for every dollar spent there have been gains of $12 saved in terms of productivity.

A DHS Nurse reports “you can always tell people throwing a sickie, because very often they haven’t decided what’s wrong with them”.

Sunday Telegraph Australia, 12 November 2006

Selenium Poisoning

A 75-year-old man had a blood test which showed an elevated prostate specific antigen (PSA). He became concerned about prostate cancer. The article does not say whether there was a suspicion of prostate cancer or whether the PSA test was done as a ‘check’. Prostate cancer is certainly common in males of this age, being found incidentally at autopsy in 40 percent of those over the age of 75 years. A screening ‘check’ of PSA cannot be defended in this case because a male diagnosed with prostate cancer at the age of 75 years is more likely to die from some other cause (ie with the disease rather than from it).

The patient visited one of “287,000 sites discussing the use of selenium in prevention and treatment of prostate cancer” and “was able to purchase 200g of sodium selenite powder without adequate instructions.” Three to four hours after ingesting 10g of the powder he presented to an emergency department, acutely unwell, and subsequently died of acute selenium toxicity.

The authors comment: “This case highlights the risks associated with failure to critically evaluate Internet material and exposed the myth that natural therapies are inherently safe”.

Medical Journal of Australia 2006, 185 (7): 388-389

Hokum Locum

Now that Terri Schiavo has been allowed to die peacefully there is an opportunity to reflect on the matter free from the hysteria and religious arguments advanced as an excuse to maintain her in a vegetative state. When discussing the ethics of the situation with a local surgeon he commented that the main problem was that the feeding tube should never have been inserted in the first place. A feeding tube is surgically inserted into the stomach through a hole in the abdominal wall. Once such medical interventions have been made it is very hard to reverse them. In this case the debate appears to have been hijacked by Catholic pressure groups.

Continue reading

Hokum Locum

Diffidence based medicine

Some doctors see a problem and look for an answer. Others merely see a problem. The diffident doctor may do nothing from sense of despair. This, of course, may be better than doing something merely because it hurts the doctor’s pride to do nothing.
New Zealand Medical Journal Vol 113 No 1122 p479

Maori Traditional health (Rongoa Maori)

I have received a letter dated Sep 30 2002 answering some questions I had asked on this matter. $1,190,000 has been allocated nationwide to 12 contracted Rongoa Maori Providers. The Marlborough share amounts to $100,000. This seemed to me a golden opportunity to have Rongoa Maori evaluated by the Ministerial Advisory Committee on Alternative Health (MACAH) but the letter tells me “The Rongoa Traditional Healing services will not be referred for evaluation by the MACAH at this time as it does not fall within their terms of reference”.

It seems to me that MACAH has become a redundant quango, much like the similar body in the US (National Institute of Health) which has also failed to make any meaningful comments on the efficacy or otherwise of any alternative medical modality. It would of course be disrespectful to Maori to test Rongoa medicine and show that it was useless.
Letter from Deputy Director-General, Maori Health, dated 30 Sep 2002.

Nuclear Test Veterans

When people believe that their health has suffered from some experience they can become obsessional and develop all sorts of strategies for defending their delusional beliefs. A British study found that veterans of nuclear tests were no more susceptible to cancers than members of the public. Sound familiar? Just think about Gulf War Syndrome and the current fuss over the spraying of the painted apple moth in Auckland.

A spokesman for the veterans was quoted as saying that the findings would not affect the push for compensation. I have seen claims from these people that as various tests were conducted they could see an Xray of their hand bones during the flash! This is fantasy and the whole thrust of the compensation issue is the belief that they were used as “guinea pigs”. There has never been any evidence that servicemen were deliberately exposed to radiation as an experiment.
Dominion Post 26/2/03

Sudden Infant Death Syndrome (Sids), Murder and logic

After a family had suffered four deaths from Sids, a woman’s estranged husband found her diary in which she documented how she had actually murdered the children. Post-mortem examinations at the time were inconclusive (Marlborough Express 2/4/03).

This case reminded me of another similar episode where a plausible woman murdered five children and was written up by a gullible paediatrician as a case of “familial Sids”, despite the protestations of an experienced pathologist who is quoted as saying: “One unexplained infant death in a family is Sids. Two is very suspicious. Three is homicide”. There is a book about this case and in my opinion it is essential reading for all Skeptics because it has so many lessons about belief, logic, flawed research and delusional thinking.
The Death of Innocents by Richard Firstman & Jamie Talan, Bantam Books

Severe Acute Respiratory Syndrome(Sars)

The media have been doing their usual excellent job of fostering panic and hysteria over a viral illness that has a mortality rate of only about 3 per cent and kills mainly old sick people. The reporting has been abysmal with no attempt to compare Sars with, say, influenza, and no intelligent discussion about mortality rates as compared to other common infectious illnesses. In my hometown of Picton there has been a run on facemasks and pharmacies are having to restock. After about 15 minutes of use facemasks become useless.

I have heard only one commentator reminding us that millions of people die every year from tuberculosis, malaria and Aids.

Variations on a Theme

When a placebo therapy becomes commonplace, it can be a good marketing tool to introduce some subtle variation which adds novelty and appeal. Chiropractic is a placebo therapy based on a plausible but unproven theory and using the power of touch (laying on of hands). The “McTimoney is a more gentle form of chiropractic involving small fast movements to release key muscles, allowing the bones to naturally move back into place”. A new local practitioner is quoted as saying “It’s very exciting. I feel a bit like a missionary”.This is quite an appropriate metaphor because many alternative practitioners have an air of religious fervour and this type of personality enhances the placebo effect.

These subtle variations of alternative medicine are unlimited and it makes good sense to use them in combination. This maximises the placebo effect.
Marlborough Express 9/4/03

Ambrotose

Placebos are sometimes referred to as “sugar pills”.It is rather fitting that Ambrotose is made from eight sugars, aloe vera and vegetable extracts. A month’s supply costs $300 so the profit margin must be huge. It appears that New Zealand has a vast population of gullible consumers with too much money. As WC Fields said: “Never give a sucker an even break”.

I have thought of a product for such people:

“Gullitose” is made from only natural sugars and salts. It is a health supplement (insert here 20 fictitious testimonials from cripples, mother of six and Aids victims) and assists the natural healing of the body. Send $400 to (insert PO Box number). Discovered by Professor Leiw PhD (University of Wakula Springs) (insert picture of jovial bearded man).

All joking aside, it is sad to think that people are wasting their money on sugar pills. $300 is a week’s wages for many people.
Dominion Post 12/3/03