Solidarity

My apologies for the long delay in posting and the dearth of new material on this post. All I can do is assure you that I am still alive, but merely very busy with my PhD and a publication... Today sciencey and not so sciencey blogs across the web are re-publishing an article by Simon Singh about the many dubious claims of chiropractors and the British Chiropractic Association in particular. I have made reference to some of the poorly-supported claims of the BCA in a previous blog entry. I've also discussed how scientists go about refuting dubious claims. Science is an adversarial system in which our claims and the evidence upon which they are based are subjected to close scrutiny and, if they appear weak, are attacked. We debate, we refute with contradictory evidence, we put forward alternative explanations for the observable facts. We do not litigate, because litigation silences a scientific debate and transfers it into a courtroom so that some lawyers can have a financially ruinous legal debate.

But the BCA sees things differently. When last year Simon Singh pointed out how weak the evidence in support of chiropractic really is, the BCA reacted not with scientific evidence, nor logical argument. They sued him. That action is now ongoing and has been commented on by Bad Science. For science to progress, debate must be free and open and won on the basis of evidence, not legal funds. This is especially important when it comes to health, because when debate about medical science is stifled, bad practices persist and the outcome is suffering and death. Whether chiropractic is effective and safe will never be determined by a judge. If any of this bothers you sufficiently, the British organisation Sense About Science have a petition you can sign.

The original Singh article (modified to avoid the BCA's litigation bat) is reproduced below, as it has been reproduced by Sharon at The Voyage, Pharyngula and many other blogs. Feel free to refute it with scientific evidence!

Beware the spinal trap

Some practitioners claim it is a cure-all, but the research suggests chiropractic therapy has mixed results - and can even be lethal, says Simon Singh.

You might be surprised to know that the founder of chiropractic therapy, Daniel David Palmer, wrote that "99% of all diseases are caused by displaced vertebrae". In the 1860s, Palmer began to develop his theory that the spine was involved in almost every illness because the spinal cord connects the brain to the rest of the body. Therefore any misalignment could cause a problem in distant parts of the body.

In fact, Palmer's first chiropractic intervention supposedly cured a man who had been profoundly deaf for 17 years. His second treatment was equally strange, because he claimed that he treated a patient with heart trouble by correcting a displaced vertebra.

You might think that modern chiropractors restrict themselves to treating back problems, but in fact some still possess quite wacky ideas. The fundamentalists argue that they can cure anything, including helping treat children with colic, sleeping and feeding problems, frequent ear infections, asthma and prolonged crying - even though there is not a jot of evidence.

I can confidently label these assertions as utter nonsense because I have co-authored a book about alternative medicine with the world's first professor of complementary medicine, Edzard Ernst. He learned chiropractic techniques himself and used them as a doctor. This is when he began to see the need for some critical evaluation. Among other projects, he examined the evidence from 70 trials exploring the benefits of chiropractic therapy in conditions unrelated to the back. He found no evidence to suggest that chiropractors could treat any such conditions.

But what about chiropractic in the context of treating back problems? Manipulating the spine can cure some problems, but results are mixed. To be fair, conventional approaches, such as physiotherapy, also struggle to treat back problems with any consistency. Nevertheless, conventional therapy is still preferable because of the serious dangers associated with chiropractic.

In 2001, a systematic review of five studies revealed that roughly half of all chiropractic patients experience temporary adverse effects, such as pain, numbness, stiffness, dizziness and headaches. These are relatively minor effects, but the frequency is very high, and this has to be weighed against the limited benefit offered by chiropractors.

More worryingly, the hallmark technique of the chiropractor, known as high-velocity, low-amplitude thrust, carries much more significant risks. This involves pushing joints beyond their natural range of motion by applying a short, sharp force. Although this is a safe procedure for most patients, others can suffer dislocations and fractures.

Worse still, manipulation of the neck can damage the vertebral arteries, which supply blood to the brain. So-called vertebral dissection can ultimately cut off the blood supply, which in turn can lead to a stroke and even death. Because there is usually a delay between the vertebral dissection and the blockage of blood to the brain, the link between chiropractic and strokes went unnoticed for many years. Recently, however, it has been possible to identify cases where spinal manipulation has certainly been the cause of vertebral dissection.

Laurie Mathiason was a 20-year-old Canadian waitress who visited a chiropractor 21 times between 1997 and 1998 to relieve her low-back pain. On her penultimate visit she complained of stiffness in her neck. That evening she began dropping plates at the restaurant, so she returned to the chiropractor. As the chiropractor manipulated her neck, Mathiason began to cry, her eyes started to roll, she foamed at the mouth and her body began to convulse. She was rushed to hospital, slipped into a coma and died three days later. At the inquest, the coroner declared: "Laurie died of a ruptured vertebral artery, which occurred in association with a chiropractic manipulation of the neck."

This case is not unique. In Canada alone there have been several other women who have died after receiving chiropractic therapy, and Edzard Ernst has identified about 700 cases of serious complications among the medical literature. This should be a major concern for health officials, particularly as under-reporting will mean that the actual number of cases is much higher.

If spinal manipulation were a drug with such serious adverse effects and so little demonstrable benefit, then it would almost certainly have been taken off the market.

The Jenny McCarthy Body Count

Perhaps in response to Jenny McCarthy's afore-mentioned comments on allowing killer diseases to come back so that the non-effect of vaccines on autism can be avoided, a guy called Derek Bartholomaus has decided to keep a running count of vaccine-preventable deaths. He's called it the Jenny McCarthy Body Count. Since she seems quite comfortable to accept that her views on vaccination will inevitably result in deaths, it seems appropriate that she should be given moral responsibility for what that means. Although Ms. McCarthy can not of course be held directly responsible for a full share of all such deaths, you get the general gist. She's in a position where her word has enormous influence, and in the case of opinions on vaccination, that influence extends to people who have no regard for her views or who many never have heard of her. The anti-vaccination movement is resulting in preventable deaths, and they had better accept that reality.

Jenny McCarthy image by Flikr user gamerscoreblog and licensed under Creative Commons Attribution ShareAlike 2.0 License.

The Streisand Effect

The Jeni Barnett MMR story really has longer legs than many of us sciencey bloggers had hoped. A week after Barnett rehashed every cliché in the anti-vaccination handbook over roughly 40 minutes of hysterical melodrama, the subsequent attempts by both Barnett and her radio station LBC to silence Ben Goldacre's perfectly appropriate criticisms have exploded hilariously in what is called The Streisand Effect. Only the Bad Science followers were paying attention up until the point when LBC's lawyers forced Ben to remove a (rather long) clip of the entire MMR segment of the show in what was a rather dubious and aggressive copyright infringement claim. The Sciencey Blogsphere Collective as not amused. The clip was rapidly copied and redistributed across the interenet, effectively becoming entirely untouchable. Blogs everywhere began to report angrily on the incident and the feeling was almost universally in favour of Ben.

In an attempt to appear open to debate, Barnett's Blog (which rather scathingly dismissed one of her most polite pro-MMR callers as "viscious") called for comments. And the comments came. 121 comments, mostly annoyed but polite attempts to explain to Jeni why MMR is safe and important for public health. A follow-on post by Barnett sneered at the "Bad Scientists" and their "sarcasm". This post prompted a further 81 comments, again the vast majority being critical of Barnett's poorly-informed and irresponsbible stance on MMR.

More blogs reported, more segments of the radio programme were posted, this time in fragments too small and too many to be silenced by questionable copyright infringment claims. Transcripts appeared. PZ Myers rallied his atheist army behind the pro-MMR standard. The Times online noticed the story, and weighed in to defend Ben Goldacre. And, in a quite stunning moment, the great Stephen Fry called for Goldacre to be supported.

Perhaps understandably, Ben's website crashed several times under the weight of visits and messages of near-universal support. Perhaps panicked, Barnett deleted all 200 or so of the critical messages from her own blog and has attempted to move on. No meaningful apology. No recognition of the continuing damage this evidence-free nonsense has done to public health in the UK and Ireland. And of course, no glimmer of having realised that everything she and LBC have done so far, including this, is just making things worse for her and her employers.

For those interested, the deleted blog comments are available at the excellent Quackometer blog.

Alternative Expectations

Scepticism is a balancing act. It’s not about a dismissive nature, any more than a credulous one. I like to think of myself as being a balanced, quite open-minded sceptic. Doubt, but don’t reject without evidence. Mind you, I get it wrong sometimes. Watching a fairly mindless piece of entertainment TV last week, I was introduced to the concept of light therapy, in particular for the treatment of depression as well as skin conditions. I could barely contain a snort of mockery as the wide-eyed presenter explained the serotonin-inducing and antibiotic wonders of various shades of intense light. Actually, I’m pretty sure I didn’t contain it at all. My automatic mistrust of the concept was hasty. After all, it is quite well established that sunlight may have all manner of influences on us, both emotional and physical. However, my scepticism led me to investigate further, which is never a bad thing. I visited Google Scholar to browse some of the peer-reviewed journals on light therapy. My aim; to find out if any evidence of the effectiveness of this therapy actually exists. Sure enough, there is some manner of science in there. Broadly, the studies performed to date have tended to be pretty inadequate in terms of sample size (rarely more than 20 patients) and time scale (weeks when we’d like years). So let’s say that the jury is still out, but that I look more favourably on the concept now than I did previously. I’m still a little dubious as to whether such treatments should already be available in clinics, when it appears as if a full-scale trial has yet to be conducted. It wouldn’t happen with a drug, after all. The wide-eyed presenter, perhaps familiar with the concept of “scepticism”, ensured us that the treatment was “scientifically proven”. Whatever that means.

So I figure that light therapy should not be dismissed. But it should certainly not be accepted on the basis of a TV personality’s assessment of what constitutes “scientific proof”. While light therapy may not be something that would conventionally be classed as “alternative medicine”, it did get me thinking about the topic. The very concept of alternative medicine is often offensive to many medics and scientists. It is a notion that thrives on the modern public’s disillusionment with science in general and the misguided concept that “another way” exists. The disillusionment is not entirely unjustified. And the philosophical rejection of reason shouldn’t prejudice our scientific judgement of the individual therapies classed under the blanket term of “alternative”. Just where did this sense of disillusionment with conventional medicine come from? I have some notions on that. Following the sudden revolution that began with the sanitation practices of the late 19th century, the western world witnessed an unprecedented improvement in public health. The work of scientists such as Koch and Pasteur did away with vague notions of the nature of disease. Ever hear of miasma theory? Nope, because it’s rubbish. Koch and Pasteur, giants of medicine, saw to it that the war upon germs could begin in earnest. Within a century the world’s greatest killers, smallpox, tuberculosis and polio, were either utterly destroyed or reduced to a shadow of their former threat. It was a true revolution. It was the end result of a paradigm shift in biology; the formulation of germ theory. But things have settled down now, we’re back to normal science. Cancer, once largely unheard of, is now the big killer. Many blame modern life, and the science that brought it, for putting things into their food and environment. The newspapers are obsessed with reporting on “things that cause cancer”, which apparently is almost everything. It’s easy to forget of course that 100 years ago very few people lived long enough to get cancer. Modern medicine’s perceived inability to “cure” cancer, heart disease and AIDS, has lead people to lose faith, even to become cynical about the means and even motives of doctors and the health industry. Of course, we scientists and doctors have not helped. Our curious culture of maintaining aloof superiority has fuelled the common man’s sense that science has become disconnected from humanity. In the absence of understandable contact from us, what has anybody to go on other than the caricatures of the media?

So, the “other way” becomes attractive. Dismissive scepticism, the worst kind of scepticism, now rules when dealing with doctors. Many have come to the assumption that alternative medicine forms part of what They Don’t Want You to Know, for reasons that are never entirely clear. A grand conspiracy. This attitude is no better than the average scientist’s blanket views on alternative therapy. It’s really just a matter of getting more information, and if we actually look for it, the beginnings of what we need to know are often already there in the journals. What should the average prospective patient look out for? The journals don’t make for an easy read, but I’ll try to summarise what makes for good testing.

In evidence-based medicine, efficacy and safety are tested using clinical studies. Because humans are so very unique and variable, the only way to be sure that a technique or drug is effective and safe is to go large. To use the biggest study groups possible. We also have to ensure that we study the effects over extended time periods. Both features are vital for the statistical analysis needed to make sense of all that human unpredictability. Most importantly of all we must use what scientists call “controls”. A control in a clinical study is essentially a group, as large and as similar as possible to the group receiving the test treatment, which is treated differently for the sake of comparison. To properly test acupuncture, for example, the bare minimum would be a study of several thousand patients with one group receiving conventional treatment, one receiving acupuncture and one receiving “sham” acupuncture in which the needles are applied but applied incorrectly. The last two groups must be “blinded”, which is to say that neither group should be aware of which is receiving real acupuncture.

A recent-ish study of acupuncture for back-pain followed this very template. They found that acupuncture beat conventional therapy for pain relief. But that isn’t the full story. Firstly, the volunteers consisted of patients for whom conventional therapy had failed. Secondly, they found that the sham acupuncture was just as effective as real acupuncture. This may be an indication of what is called the placebo effect. This is an apparent beneficial effect caused by a fake control treatment, be it the administration of a sugar pill or random pinpricks. Or perhaps there’s some peculiar value to being poked with needles in general. Put simply, it’s not clear what’s going on there. Acupuncture must remain in the realms of the untested for now and we should treat it as such. With doubt, but not with contempt.

On the flip side, we can ditch reiki and reflexology as they have been tested quite thoroughly and found to have no greater benefit than a massage. “Allergy tests” based upon applied kinesiology (the one where bottles of varies substances are held near your muscles) are pure and utter witchcraft in my view. There’s no connection between the results of these and the standard medical allergy test. Hell, some of those tests use sealed bottles, so quite how your body could ever react to the contents is a mystery. As for chiropractic... don’t get me started. Few studies have been able to demonstrate anything more than a placebo effect. Most damningly of all, as pointed out by Ben Goldacre, some chiropractors would rather block the process of scientific criticism of their field. The New Zealand Chiropractors Association has taken the highly suspicious step of attempting to sue a peer-reviewed journal. With your health on the line, is this the sort of carry-on you should accept from your doctor? (Author's Note 21 Aug 2008: The British Chiropractic Association are also sueing journalist Simon Singh for an allegedly libellous article on their faith. I mean, science.)You can be quite sure that no reputable scientist has ever sued in response to academic criticism. Proper studies such as I outlined above are hard to conduct on chiropractic spinal manipulation. This is primarily because the medics who usually run studies are not trained in the methods and chiropractors are reluctant to get involved. What information there is tends to be both limited and self-contradictory. This isn’t a nail in the coffin by any means, but it’s clear that the professionals could be doing more to make us trust them. The general folk and herbal medicine scene is a whole can of worms in its own right. It’s quite clear that some of it works, after all many modern drugs are derived from plant and fungal components. But it’s clear that we don’t know enough about the complex mixture of active ingredients in many such preparations to draw generalisations. Much like light therapy and acupuncture, it remains for me at the fringes of reason for the time being. Ultimately, the advice for navigating the maze that is alternative medicine is much the same as my advice regarding the reading of science in the mainstream media. Scepticism, but open scepticism. Demand evidence, statistics and hard facts. Mechanisms must be rooted in what we can observe. As for doctors, expect more from them too. Ask for explanations, don’t just accept prescriptions. Doctors are often impatient with patient questioning and take a dim view of patients coming to them with their own research from books or the internet. This needs to change. Try to open a dialogue, one that is respectful and yet still sceptical. Never forget that your doctor has some ten years of training and perhaps decades of practical experience. The relationship should ideally be a two-way communication.

As for “alternative medicine”, the term encompasses too wide a range of ideas and carries too much prejudice. To my mind there should be only two kinds of medicine. Tested and not. Only the successfully tested has a place in our lives. Much of what is now untested may one day be worthy of our trust, but right now our health and our lives are at stake. Nothing is more valuable, and nothing is more worthy of healthy scepticism.