neuronical.com

A creationist commenter on a post of mine discussing lame creationist arguments first admitted that he did not actually read my post, and then began to repeat the same tired creationists lies and logical fallacies we hear over and over again.

I had asserted a well-established biological fact – the eye is not irreducibly complex. There are examples in nature of simpler eyes that represent probable stages through which the vertebrate eye evolved. I made this as part of a broader point, that many structures and systems claimed to be irreducible have known simpler antecedents, and I even provided a link to a page on Talk Origins that linked in turn to many articles with the evidence for this claim.

Creationists, however, are apparently not interested in making sound arguments or what science actually has to say about any particular question – only obfuscating the truth with misdirection and debating tactics. The commenter claimed I had not bothered to provide evidence to back up my claim, and inferred that I therefore could not.

He wrote:

That link has absolutely nothing to do with scientifically showing that these two biological systems, specifically vision or blood clotting could have evolved from simpler systems that were functional but served a different purpose from their current one. It is no different than your approach – simply declare that the argument is flawed without specific scientific proof to the contrary but broad statements of the sort …”that is wrong and this is how it works,” without any proof.

He then challenged me to provide evidence for simpler antecedents in eyes. Well, challenge accepted. Of course, what he is really saying is that he is too intellectually lazy and/or dishonest to find the information himself. It is not hidden away in dusty university libraries – it’s just a few Google clicks away.

Without much trouble I was able to find links documenting what I had read from many sources – there are multiple examples of living creatures with simpler eyes – highly functional, often adapted specifically for their function, and representing a plausible path of the evolution of vertebrate eyes from nothing but a patch of light sensitive cells.

I will anticipate the likely creationist misdirection – these examples do not represent an actual evolutionary sequence. Of course not – they are examples from extant (living) species – all of whom share a common ancestor but represent current examples of many different lineages that split off at various times in the past. They are not a sequence.

The point of these living examples is to refute the claim that the eye is irreducibly complex – that if it were any simpler it could not function, or more specifically could not confer an evolutionary advantage to the host.

Eyes are soft tissue – they do not generally fossilize. So we have scant fossil evidence of eye evolution. We do have some, from species with preserved skull bones showing muscle insertions and the structure of the tissue around the eye (for example), but not the soft parts of the eye itself.

Here are some simple eye structures that work just fine for the organisms that have them:

Eye spot – patch of tissue or cells that are photosensitive. Organism can move toward light, or synchronize circadium rythm, but not see shapes.

Example: Euglena

Once you have an eye patch, the next step is for the patch of cells to become progressively depressed. This increases progressively the ability to distinguish direction, each step providing a slight advantage, until you have an Eye cup. Eye cups are able to tell direction of light better than eye patch – the more cupped the eye, the finer the angle of discrimination.

Example: Planarian

When an eye cup continues to deepen, eventually the outer rim of the cup with close in on itself, forming a Pinhole eye. The pinhole eye works like a simple camera, and is able not only to distinguish direction quite well but also make out basic shapes.

Example: Nautilius

A pinhole is still open to the outside world, however, so the formation of a transparent cell layer over the hole has an obvious advantage. Once this happens, that opens the door for layering and specialization, including forming a pocket of cells to act as a lens. A primitive lens would focus light into the eye, increasing the amount of light falling on the retina. Before this was sufficiently refined for the lens to focus an image sharply on the retina, a weak primitive lens would still amplify light. This would allow sea creature to see at greater and greater depths, until they had a strong lens that could focus in on the retina.

Example:  Box Jellyfish - have primitive lenses that do not focus, adapted for low light environments. Jellys in brighter environments have simpler eyes without lenses.

And now you have all the basic elements of a vertebrate eye, requiring only progressive refinement.

Again – this line of evidence does not prove that or how the vertebrate eye evolved. It simply demonstrates that simpler eyes, all the way down to a patch of light sensitive cells, could work and provide an adaptive function – therefore the eye is not irreducibly complex.

There are other lines of evidence, however, from genetics, fossil evidence, and the suboptimal design of the vertebrate eye, that point directly at evolution.

Of course this evidence will not stop trolling creationists from leaving comments claiming the eye could not have evolved because it is just too complex. Creationists have a flat learning curve when it comes to evolution.

Addendum: I also found this article: Evolution of the vertebrate eye: opsins, photoreceptors, retina and eye cup.

This is a nice article published in Nature that reviews the evolution of the vertebrate eye giving examples of the various simpler stages with vertebrate relatives. In other words, this is as close to an evolutionary sequence as we can get with extant species. This goes beyond plausibility, and beyond demolishing irreducible complexity, to documenting the evolution of the vertebrate eye specifically.

It is ironic that creationists continue to use the eye as the example of the complex structure that defies evolutionary explanation – when in reality the various eyes that have evolved in nature represent one of the best lines of morphological evidence for evolution.

I love a good sequel. Aliens, of course, was the best sequel ever – that rare event when the sequel is actually better than the original movie (of course, the series went down hill from there, like Star Trek it peaked with the second movie).

Last year we heard the results of the Autism Omnibus – a special court with three special masters set up to resolve about 5,000 cases before the vaccine court claiming that autism resulted from vaccines – either the MMR vaccine or thimerosal (a mercury-based preservative in some vaccines, but removed from most by 2002). In the US there is a Vaccine Injury Compensation Program (VICP) which bypasses the regular courts and awards compensation to those injured by vaccines, paid for by a small tax on each dose of vaccine given. The purpose is to rapidly compensate those who might have been injured (the threshold for evidence is quite low) and to encourage pharmaceutical companies to manufacture vaccines (the threat of suit would make it not viable otherwise).

Over 2008 the Autism Omnibus heard three cases that were presented as the test cases (presumably the best cases they could come up with) for the theory that the  MMR vaccine (with or without thimerosal from other vaccines – MMR never had thimerosal) caused or contributed to autism in some individuals. They ruled against all three cases, stating in very strong terms that there is no evidence to back up the claims of a link between MMR and autism. Judge Hasting wrote of one case – Cedillo:

Considering all of the evidence, I found that the petitioners have failed to demonstrate that thimerosal-containing vaccines can contribute to causing immune dysfunction, or that the MMR vaccine can contribute to causing either autism or gastrointestinal dysfunction. I further conclude that while Michelle Cedillo has tragically suffered from autism and other severe conditions, the petitioners have also failed to demonstrate that her vaccinations played any role at all in causing those problems.

This was a huge blow to the anti-vaccine crowd, and an excellent victory for science and reason. It was the equivalent of the Kitzmiller vs Dover trial for Intelligent Design.

In fact, it reinforced my respect for the judicial process in hearing scientific cases. Stephen J. Gould once observed (I think in reference to Creation Science trials of the 1980s – and I am paraphrasing) that when there are rules of evidence, science generally triumphs over pseudoscience. Pseudosciences, like anti-vaccine nonsense, intelligent design/creationism, and homeopathy – do not fare well when their shenanigans are inspected under the patient and penetrating glare of a thorough trial. Pseudosciences depend upon cherry picking evidence, using logical fallacies, distraction and diversion – all tricks which are exposed by a court following rules of evidence and logic, and taking the time to review all the evidence. We now have a series of high-profile cases in which Gould’s observation is confirmed.

Of course, we always worry that such cases will be decided on matters of law rather than matters of evidence, and then be misinterpreted as confirmation of the pseudoscience. This happened in the 1980s when chiropractors were successful in a restraint of trade suit against the AMA, and then later claimed this was a vindication of chiropractic (it wasn’t). But that’s another story.

In any case, generally science does well in controlled settings, and this past week we saw another example. The Autism Omnibus Court rendered their second set of decisions regarding the next three test cases – this time focusing on the hypothesis that thimerosal causes autism. In all three cases they ruled solidly against the petitioners, stating that they did not make their case. The ruling was not just negative – like the Dover decision, it was a harsh condemnation of the case put forward by the lawyers for the petitioners.

You can read the full decisions here: George and Victoria Mead, Fred and  Mylinda King,  and Timothy and Maria Dwyer. While expressing sympathy for the parents and their children, the masters ruled against every aspect of the case they brought forward. For background, autism is an “off table” injury claim – there is no presumption of causation, but petitioners must demonstrate their case with a “preponderance of evidence.” This is a lower standard than would be used in science, and the decision is limited to whether or not compensation is appropriate – not the ultimate scientific conclusion.

Here are some highlights from the decisions:

Support for petitioners’ claim does not come from the epidemiologic evidence, and petitioners’ claim that the performed studies lack the requisite specificity to detect an association between the receipt of thimerosal-containing vaccines and the allegedly small subset of cases involving autism with clear signs of regression is unavailing.

Petitioners have not shown either that certain children are genetically hypersusceptible to mercury or that certain children are predisposed to have difficulty excreting mercury. The scientific validity of the studies on which petitioners rely has been
questioned and the conclusions drawn from the studies have been criticized as unsupported.

While petitioners have alleged correctly that inorganic mercury can remain in the brain for a period of time, petitioners have not shown that the inorganic mercury deposited in the brain–in the amount that could be received from a full complement of thimerosal containing vaccines–can cause the effects that petitioners have alleged.

If you will excuse a somewhat longer excerpt, this section on the claim that response to treatment with chelation proves mercury caused autism, is a good example of the kind of analysis used in the hearing:

Respondent’s experts Dr. Rust and Dr. Fombonne argued persuasively that it would be inappropriate to draw any inferences concerning causation, in Jordan’s case or any case, from Dr. Mumper’s testimony concerning treatments, for several reasons. First, they pointed out that the treatments to which Dr. Mumper referred have not been demonstrated by scientific testing to have any beneficial effects on autism in general. Dr. Brent provided similar testimony.

Second, respondent’s experts explained that autistic children quite often have periods of substantial improvement in their symptoms in the absence of any treatment, so that it is not reasonable to conclude that a particular period of improvement was caused by any recent treatment.

Third, respondent’s experts noted that because Jordan was often subjected to more than one treatment at a time, it is even more dubious to ascribe any improvements to particular treatments. (Ex. M, paras. 46, 142-43; Tr. 2459-60, 3697-99.)
Moreover, it is clear that chelation treatments do not remove mercury from the brain, so it is not logical to conclude that such treatment could affect autism.

In this regard, on cross-examination Dr. Mumper herself acknowledged that she could not 108 explain how the other treatments upon which she relied could, even in theory, affect the persistent inorganic mercury in the brain that she believes to be a contributing cause of autism.

and…

In concluding that petitioners have failed to establish that Colin’s TCVs caused his ASD, I emphasize that I have not applied a heightened evidentiary burden. I did not require scientific certainty, nor direct evidence of causation. Daubert requires that an opinion be supported by something more than subjective belief; it must be grounded in “the methods and procedures of science.” 509 U.S. at 590. There is no evidence that mercury has ever caused an ASD, only speculation that it might. At best, there is some evidence of an ongoing inflammatory process in ASD, but no indication that it is caused by mercury, and many indications that it is not.

This last paragraph has two points I want to highlight. The first is the citation of the standard of evidence used – as I said, less than scientific proof, but it must be based on something. The second is that Special Master Vowell acknowledges that there is no evidence “mercury has ever caused an ASD (autism spectrum disorder).” This is in contrast to the claim by some anti-vaccinationists that the VICP has admitted vaccines cause autism in some cases. They have not. They have only decided in certain cases that “compensation is appropriate” and in the cases often put forward, such as the Hannah Poling case, the child did not have autism but some other neurological disorder.

Conclusion

This most recent decision by the Autism Omnibus is a slam dunk – after an exhaustive review of the evidence, allowing both sides to present their best case, the three masters are unanimous in their strong opinion that there is no evidence linking thimerosal to autism. They trashed every claim and argument brought forward by the petitioners – the logic and evidence simply does not support their case.

Of course, the anti-vaccinationists cannot accept the unavoidable conclusion – the current evidence simply does not support their claim. So they predictably retreat to conspiracy-mongering. Read the comments to any anti-vaccine blog on this topic – there is the casual assumption that the masters (along with the CDC, AMA, FDA, AAP, and every science-blogger) are in the pockets of evil “big pharma”. They have their narrative, and they will not be distracted by anything so pesky as facts and evidence.

While this is a huge win, there is another case on the horizon that is the cause of some concern – Bruesewitz v. Wyeth. The Supreme Court has agreed to hear this case, which will test whether or not a family can sue a pharmaceutical company for an alleged vaccine injury and bypass the VICP. This case will be decided by the law – not science – and so I have no idea which way it will go. If the Supreme Court rules that people can bypass VICP this will undercut one of its primary functions, and the flood gates will open. Anti-vaccinationists could make it untenable for pharmaceutical companies to market vaccines.

While I applaud this follow up to the Autism Omnibus hearing, I hope it does not follow the pattern of Aliens and Star Trek and peak with the first sequel.

Note: Orac has also written a good review of this topic.

Texas is becoming a recurring spectacle of the triumph of anti-intellectualism and ignorance over science and reason. The substance of this spectacle is the Texas Board of Education (BoE) and the standards for public school textbooks. This is a local triumph, but it has widespread implications, as Texas is a major purchaser of textbooks, and so the industry generally caters to the Texas standards.

Last year our attention was drawn to the Texas BoE over the science standards, with particular attention to evolution. One member in particular, Don McLeroy (who was chairman but was removed) entertained (by which I mean frightened) us with phrases such as “someone has to stand up to those experts.” The particular controversy was over whether or not to insert language into the standards that opens the door for teachers to “question evolution,” meaning to insert creationist propaganda as science.

The new language that was put in includes that students must “analyze, evaluate, and critique scientific explanations” based in part on “examining all sides of scientific evidence of those scientific experiments.” Language was also put in to specifically question the age of the universe, the nature of stasis and change in the fossil record, and the complexity of the cell and information in DNA.

This year the focus of the Texas BoE is to review the standards for world history, and amazingly they have been as successful in causing mischief as they were with the science standards. Don McLeroy is still on the BoE, however he recently lost his reelection bid, and so will be out at the end of the year. Meanwhile, he promises to go full steam ahead with his admittedly religious conservative agenda. (See the Nightline interview from Thursday 3/11 for details.)

The Texas BoE, with or without McLeroy, is dominated by Christian Conservatives. This is not inherently a problem, in my opinion, as long as everyone is dedicated to performing their duty rather than using their position to promote their personal ideological agenda. Alas, that does not appear to be the case.

Carl Zimmer reports that the board voted to remove specific references to the Enlightenment (yes, the Enlightenment) and to (wait for it) Thomas Jefferson. Can there be a better metaphor for the fact that the Texas BoE is unenlightened and they desire Texas students to be unenlightened also?

What’s their problem with Thomas Jefferson – we can only imagine. They argued we was superfluous, which is absurd. Could it have something to do with the fact that Jefferson was the primary architect of the separate of church and state, and that he himself was a deist?

In addition, the BoE has voted to engage in a bit of historical revisionism, among other things voting to insert language that suggest the McCarthyism witch hunts of the 1950s were justified and later vindicated. They also voted for removing reference to Thurgood Marshall, and inserting references to the rise of conservatism in the 1980s, the Moral Majority, and the Contract with America.

History textbooks have always had the problem of political bias (remember the old adage that the victors get to write the history books), and it would be misleading to suggest this is a local or new problem. I also probably risk some of your ire by suggesting the Texas BoE is not entirely wrong when they argue that history textbooks have an existing liberal bias. I remember enough of my high school American history class to believe this is probably true. In fact, we had a discussion in class about bias in history books, discussing in particular the treatment of Richard Nixon with that of Millard Fillmore – the point being that the closer you get to the present, or to issues that are still controversial, the more bias becomes an issue.

The goal should be to eliminate all bias from the textbooks, including (especially) our own. If there is a liberal bias, then let’s have a balanced review and do our best to fairly present history from every perspective and with as little bias as possible. The Texas BoE has not chosen this path. Rather, they have chosen to simply insert as much of their own conservative bias as possible. This does not “balance” the history textbooks, however – it simply inserts more biased history.

It seems to me that one solution, perhaps the best, is to review the history texts with as broad and cosmopolitan a view as possible. This will allow for local biases to average out and for a consensus view to emerge. This very solution has been proposed by state governors – who have suggested the creation of national educational standards to replace state standards (a project called common core).  While they are starting with math and English, this could also apply to science and history.

This idea was proposed to solve the debate over the role of the federal government vs state governments in education. States have resisted federal standards – but this system is a voluntary system proposed by the states themselves. So far every state but two has signed on – the holdouts are Alaska and (you guessed it) Texas.

Another potential solution is to dampen the power of the textbook industry over the quality of our educational system, and by extension the power of the Texas BoE. One way to do this is to simply create high quality textbooks and make them available for free online. I think this is the future anyway – why print outdated material when you can have updated online material.  Material can be printed as needed off the online textbooks, especially for use by school systems with limited computer resources. There are already online wiki-style textbooks being developed. What we need now is a non-profit dedicated to organizing these efforts and imposing a system of quality control. I strongly suspect that the quality such a process would produce would be far superior to the crap the textbook industry generally produces.

Conclusion

The Texas BoE is a depressing spectacle – they represent the absolute worst example of abusing authority to promote a personal ideology, betraying the public trust to promote instead high educational standards. But perhaps the spectacle can be put to good use, focusing attention on the broader problem of the quality of education in the US and potential solutions. We need better and more uniform standards, and better textbooks.

In his Nightline interview McLeroy acknowledged that the Texas BoE has an influence that goes far beyond Texas – so they are acutely aware of the power they wield and choose to abuse it anyway. Perhaps it is time to move away from the tyranny of local majorities in education, to more consensus and quality-driven standards.

Neuroscientists are making steady progress in mapping the brain using fMRI and other new techniques. Researchers at the Wellcome Trust Centre for Neuroimaging at UCL (University College London) have been publishing a steady stream of interesting results.

It has been known for some time that the hippocampus, a small structure in the medial temporal lobe, is important for learning and memory. The structure gets its name from the seahorse, because it looks curled up like the tail of a seahorse. Many details of the anatomy and function of the hippocampus remain to be explored, and the new technology is providing a useful window.

Recently it was discovered that the hippocampus contains what are called place cells – neurons that are activated according to our location in three-dimensional space. These neurons, in essence, process information relating to our location. However, it was not known whether or not these cells are laid out in the hippocampus in a predictable pattern, or if they are essentially random from person to person.

Demis Hassabis and Professor Eleanor Maguire at the Wellcome Trust Centre published a study about a year ago looking at human volunteers while walking around a virtual space. By analyzing the activity of their hippocampus with a computer algorithm they developed, they were able to predict greater than chance where the subjects had been. This strongly implies that there is a regular pattern to the layout of place cells in the hippocampus. Like most anatomical structures, there is almost certainly a great deal of individual variation around a basic layout. This means that greater success rates might be achieved if the algorithm were first calibrated to an individual – perhaps a subject of future research.

Now the same team has published follow up research involving subjects looking at three films, all involving women on a city street performing some task, like mailing a letter. Afterwards they were placed in an fMRI and asked to recall each of the films in turn. The computer algorithm was then able to analyze the pattern of activity in their hippocampuses (there is one on each side) and predict greater than chance which of the three films they were watching. This supports the hypothesis that there is some regularity to the layout of neurons in the hippocampus.

Of course these preliminary results led to extrapolation of this technology to the potential of “reading minds”. This may be theoretically possible, but don’t hold your breath. We are a long way away from the Matrix, where an almost flawless reality can be jacked directly into, and read from, the brain.

What is certainly true is that we are in the middle of an exciting time in neuroscience where new tools have accelerated the research, allowing us to map and understand the brain better than ever before. It seems likely that we will continue to make incremental improvements in our ability to model the brain, and even interpret brain activity. There are researchers mapping out the visual cortex, and able to use fMRI to see what a person is reading. And these researchers are able to see where a person has been or what location they are thinking of (from a limited set of choices).

However, these applications represent the low-hanging-fruit of this research – areas of the brain that are visuo-spatial where the brain has some degree of topical mapping. In other words, the neurons in the brain are laid out physically in a way that maps to the visual or spatial data they represent. The same is true of the motor and sensory cortex – there is, in fact, a homunculus – a representation of the body laid out along the motor cortex and  the sensory cortex.

As we get to other areas of the brain, however, it remains to be seen how much this somatotopic mapping will hold up. Abstract areas of the brain involved with math, language, emotion, and similar functions may not be so conveniently organized. I also imagine that the level of complexity will increase not linearly but geometrically or even exponentially. Further, the amount of variation will likely also increase significantly. Systems used to read brain activity may require exhausting calibration.

But there is nothing inherently impossible about such mind-reading technology, it is just likely to become increasingly difficult and complex. I liken it to the problem of artificial intelligence. Fifty years ago computer scientists were starting to see Moore’s Law in action, with steady and stunning increasing in computer power. They optimistically extrapolated that increase and predicted that human level computer intelligence would be reached in 20-30 years. We thought nothing in 1969 about the HAL computer in the movie 2001 – sure, in 32 years we will have AI. How cool.

But the AI problem turned out to be much more difficult than anticipated, not just a matter of simple extrapolation from existing advances, and now we still seem to be 30-50 years away from true AI approaching human level intelligence. Maybe there will be unanticipated hurdles still.

Mind reading computers will likely follow the same pattern. We will make incremental advances, but the real futuristic applications may be more challenging than we think. It is difficult to impossible to predict such things, however. While everyone overestimated our ability to develop AI, everyone also underestimated the true power of computers to revolutionize communication.

As an aside, there is some other recent research involving the hippocampus. As I stated, the hippocampus is involved in both memory and learning. Recent research, however, suggests it may be involved more in processing information than just storing it. These researchers ran rats through a maze and then looked at their hippocampus function with fMRI. They found that the pattern of activation in the rats following learning the maze did not match the routes they learned, but rather correlated to other parts of the maze they explored, and even to parts of the maze they never ventured into.

The researchers interpret this study as possibly meaning that the hippocampus was processing the visuo-spatial information of the maze – going over possible routes and reconstructing the maze, even the parts the rats did not directly explore. They conclude that the hippocampus may be more important for information processing than memory.

It is difficult to make too much out of a single study, but the research does suggest the role and function of the hippocampus may be more complex than existing models suggest (which I think we can assume is probably true of all our current brain models). It also reinforces what I have seen from other research – that memory and information processing are closely linked.

One thing is certain – it is an exciting time for neuroscience.

Acupuncture is a so-called complementary and alternative medicine (CAM) modality I frequently tackle because it often provides excellent  teaching points on the relationship between science and the practice of medicine. My reading of the literature is that acupuncture is highly implausible and the evidence does not support its efficacy for any indication.

And yet it is one of the more popular CAM modalities (although still a small phenomenon – only 6% of Americans have ever used it), especially in its penetration of hospitals and academia. There is a great deal of misinformation out there about acupuncture, and this seems to garner the most attention from naive physicians.

In vitro fertilization (IVF) is one of the applications of acupuncture that has been most touted by proponents. The evidence for any positive effect from acupuncture for IVF, however, has been consistent with no effect. By this I mean that there are poor quality studies with mixed results, but trending positive (as poor quality studies tend to do), especially in China and other nations culturally predisposed to acupuncture, but the better designed studies tend to be negative.

There have been a number of systematic reviews of acupuncture trials for IVF with mixed opinions. The most recent review was conducted by the British Fertility Society, and they conclude:

The guidelines found that there is currently no evidence that having acupuncture or Chinese herbal medicine treatment around the time of assisted conception increases the likelihood of subsequent pregnancy.

They reviewed 14 randomized controlled trials and performed meta-analyses on the various outcomes and timing of treatment, and in all cases found no difference between acupuncture and control groups. Other systematic reviews have also come to the same conclusion, for example this 2008 review concluded:

Currently available literature does not provide sufficient evidence that adjuvant acupuncture improves IVF clinical pregnancy rate.

Yet other reviews came to different conclusions. This BMJ review from 2008 concluded:

Current preliminary evidence suggests that acupuncture given with embryo transfer improves rates of pregnancy and live birth among women undergoing in vitro fertilisation.

Why the discrepancy? Partly it is due to a judgment call – the difference between “preliminary evidence is positive” and “there is insufficient evidence” – which is likely a result of the biases of the reviewers. How much weight do you put on preliminary evidence. Those reviews that emphasized the best studies (which I think is the appropriate approach) showed no effect from acupuncture.

One of the best studies of acupuncture in IVF was this one published in 2009. They found that placebo acupuncture was better in some measures than true acupuncture, although no better in others. The authors should have concluded that acupuncture simply does not work, and that these differences found were likely due to chance. However, they concluded that:

Placebo acupuncture was associated with a significantly higher overall pregnancy rate when compared with real acupuncture. Placebo acupuncture may not be inert.

This is just bizarre, but not uncommon in the CAM world. It is just a form of special pleading to argue after a negative trial that placebos work also. In this study the authors are left trying to justify the conclusion that placing the needles in the “correct” locations had a disadvantage over placing them in random locations, which would also mean that expertise in acupuncture is a disadvantage.

Proponents of acupuncture, following the BFS announcement, were quick to insulate themselves from the evidence using special pleading.

One high-profile practitioner, Dr Xiao-Ping Zhai, of The Zhai Fertility Treatment Clinic, said there were indeed problems with the way in which these trials were designed and that different analysis would show the benefits.

“Certainly for those with unexplained fertility problems in particular, we know acupuncture and traditional Chinese medicine can be beneficial. What matters is both the expertise and experience of the practitioner, but most of all the treatment of the patient as an individual. It is the tailored treatment which is key.

My primary question for Dr. Xiao-Ping Zhai is – how does he know that acupuncture works to improve IVF success? He seems to be taking the classic pseudoscientific approach of using science to validate beliefs, rather than test them. When controlled trials are negative, proponents then blame the trials – they must be wrong, because they “know” that acupuncture works.

One of their tactics is to claim that acupuncture needs to be “individualized” – using a standard treatment does not work. But they are unable to provide a coherent explanation for why individualization should matter, at least in physiological terms. Invoking “life energy” and the flow of “chi” is nothing but superstition.

But even if we grant for the sake of argument that individualization of treatments makes a difference, that does not mean the existing trials are wrong and acupuncture works. At best it means we still do not know if acupuncture works for IVF. It is now on the proponents of acupuncture to design and execute what they claim are better trials that allow for individualization.

The problem with this historically is that such trials sacrifice some of the blinding in order to individualize. They have to be especially careful in their design to accomplish both ends – individualized and properly blinded. This has been done, in acupuncture for back pain, for example, with no difference between standardized and individualized treatment groups. So far the “individualization” special pleading has not been supported by the evidence.

“Expertise and experience” also does not seem to matter. This is just another claim without evidence. It may seem intuitive that experience should matter, but actually it matter far less than experts (including physicians) would like to think. To clarify this point – this is in the context of applying treatments. Generally speaking, following evidence based guidelines yields better results than shooting from the hip based upon personal experience.

I would also argue that expertise in a pseudoscientific discipline should be considered pseudoexpertise. Knowing where to place acupuncture needles according to complex Traditional Chinese Medicine principles would only matter if the TCM principles were valid. However, the totality of acupuncture research is consistent with the interpretation that it does not matter where you place the needles – so all that expertise appears to be worthless. It is the equivalent of being able to provide an expert astrology reading – expertise in astrology matters not, because astrology is 100% nonsense.

At the very least, if proponents are going to argue that existing evidence against the efficacy of acupuncture for IVF should be dismissed because the treatments were insufficiently individualized or that they were given by insufficiently experienced practitioners – they should provide evidence that either of these things matter. And even worse, they are committing the logical fallacy of concluding not only were the trials not definitive, but that acupuncture works (rather than it is still unknown).

What about plausibility? Proponents argue thusly:

A statement from the British Acupuncture Council noted: “Fertility focused acupuncture treatment has been found to help increase blood flow to the reproductive organs, balance hormone levels, regulate the menstrual cycle and help improve the lining of the uterus and quality of eggs released.”

This is a common ploy by proponents of dubious treatments – they cite research which essentially amount to anomaly hunting – looking for physiological changes that correlate with the treatment. First it must be pointed out that basic science evidence, like physiological changes, should not be used to extrapolate clinical claims – the clinical evidence for efficacy must also be there, and it isn’t.

But the more subtle point is that medical researchers are familiar with the fact that if you do something to an organism or a clump of cells and then look for changes, you will find them. Biological systems respond to stimulation. Stick a needle in someone and there will be a local inflammatory reaction, causing a host of changes.Are any of these changes actual markers or causes of a specific clinical effect? That is a different question.

Further, biological systems are highly variable, so looking for changes is often rewarded. Knowing what those changes actually mean is another matter.

When anomaly hunting for physiological changes is rewarded, proponents also often make another unjustified leap of logic, assuming that “changed” equals “improved.” So changes in hormone levels becomes “balance hormone levels” – without any evidence that the non-specific changes represent a functional improvement.

The take-away message is that finding changes in physiological markers in correlation with a treatment is helpful in designing future research and both testing and generating hypothesis – but they are no substitute for clinical research. Finding physiological changes is also not as impressive as is often presented – it is actually an extremely poor predictor of clinical efficacy. Anyone doing translational research is keenly aware of this – most treatments that are promising based upon pre-clinical evidence do not pan out clinically.

Conclusion

Acupuncture remains an implausible treatment, and lacks sufficient evidence to conclude that it works for any specific indication. The history of acupuncture research is following a familiar pattern. Initial research is mixed but trends positive. Basic science research shows non-specific anomalies, but no consistent pattern that accords with scientific theory of mechanism for acupuncture. For each indication, as better and more rigorous studies are designed, the effects shrink until the best studies are negative.

Proponents then engage in special pleading to dismiss the evidence, while simultaneously citing poor quality or pre-clinical evidence, secure in their faith that acupuncture works.

We see this pattern with homeopathy research, the ESP literature, UFO investigations, and all manner of fringe science. Recognizing this pattern is essential to interpreting any large body of such research.

I received the following question from an SGU listener:

Recently when I visited a neurologists with my daughter to seek help for her migraines the doctor prescribed something that caught me off guard and in my research since the visit I still have not convinced myself of the validity. The doctor told my daughter she should start taking magnesium supplements. The doctor told her this would serve as a natural muscle relaxant.
I have been listening to your podcast for about 6 months now and enjoy it very much. I enjoy the entire crew and would really like your team’s take on the Migraine and Magnesium relation.

This is an excellent question, and reinforces the notion that science-based medicine is not about a list of acceptable beliefs or modalities – it is about method. There is nothing inherently implausible or unscientific about using vitamins, minerals, or other nutrients to address diseases or symptoms. All that matters is the science.

However, the current state of loose regulation did result in an explosion of the supplement industry, with a multiplication of dubious claims. This had the additional consequence of drowning out legitimate nutritional advice with all the nonsense, in a “boy who cried wolf” phenomenon. Now the skeptical consumer is and should be wary of any and all supplement claims.

Magnesium for migraine is a plausible hypothesis. Magnesium can affect both regulation of blood flow and neuronal function – both of which are physiological factors important in migraine. There is evidence that magnesium deficiency is common, and is more common in migraine patients than non-migraine sufferers.

But the basic science is complex, and there is evidence that low magnesium in brain tissue may be a side effect, and not a cause, of the physiological mechanisms of migraine. So the bottom line is that magnesium as a treatment for migraine is plausible, but there are still unknowns.

The clinical evidence needs to be divided into specific clinical claims: magnesium as a treatment for children vs adults, migraine with aura vs migraine without aura, acute treatment of migraine attacks vs migraine prophylaxis, and treatment of menstrual migraines.

Here is my quick summary of the evidence: There is preliminary evidence only in children, and more research is needed. Treatment of acute attacks with IV magnesium sulfate has mixed evidence, but more positive than negative. One study showed, however, that it can decrease the effectiveness of medication for nausea, often given to treat the nausea of severe migraines.

There is more evidence for migraine with aura than without, but probably not enough to make a critical difference. The best evidence is for menstrual migraines.

Overall the evidence for prophylaxis shows a small but significant effect. Evidence is still preliminary, and large definitive trials are needed to fully settle the question.The effect seems to be smaller than for other nutritional interventions for migraine, specifically vitamin B2 and Coenyzme Q10, and all the supplements are less effective than the best prescription medications.

As a neurologist who treats migraine frequently, I also have experience using magnesium. This is how I put it all together: Most of my patients have not noticed a significant improvement with magnesium. While it is safe, in the doses used for migraines (400-600mg per day) diarrhea can be a significant side effect, and many of my patients stopped using it or had to decrease the dose for that reason.

While the evidence is preliminary, it tends to be positive and so magnesium is a plausible and generally benign treatment option  (if you don’t get diarrhea). It may have a role more as adjunctive treatment (in addition to other treatment) rather than stand-alone treatment because the effect is modest.

Typically I will check the magnesium level in patients with migraine and supplement magnesium if it is low. These patients may represent a subset that responds to magnesium, and in any case they are low in magnesium and probably should be supplemented anyway.

Overall magnesium has a minor role to play in the management of migraine. We could benefit from larger studies to more definitively clarify its role in the various clinical situations I outlined above, primarily because it is inexpensive and relatively benign.

I do not think that the evidence supports using magnesium as a primary treatment for migraine before other more effective treatments. However, some patients may wish to give it a try in the hopes of avoiding medication, and that is reasonable.

The use of magnesium in migraine is a good example of how a science-based practitioner might incorporate benign and plausible treatments but with only preliminary evidence into their practice.

It seems as if the wave of H1N1 pandemic flu has passed, so it is a good time to get up to date on the status of the pandemic. For background, the H1N1 is a strain of influenza A  that cropped up about a year ago. It was declared a pandemic by the World Health Organization (WHO) last Summer.

The pandemic spawned a number of controversies. The last H1N1 outbreak, called the “swine flu” (a bit of a misnomer) was in 1976. The vaccine for that strain caused Guillaine Barre Syndrome (GBS) in about 1 in 100,000 people vaccinated. Therefore with the roll out of the new H1N1 vaccine there were cries from the usual assortment of anti-vaccine and other cranks that the vaccine would cause GBS, even though the last 30 years of seasonal flu vaccine has not caused any such outbreaks (at worst the seasonal flu vaccine causes an extra one case of GBS per million doses, but even this is questionable).

There were also accusations that the flu pandemic was a scam created by Big Pharma to sell vaccines, and the real conspiracy nuts claimed that the vaccine was in fact designed to infect and kill people.

Meanwhile, there were questions (legitimate and nutty) about how severe the pandemic actually would be. Of course, no one could know until after it happened.So how bad was it? Here is the updated numbers from the CDC:

# CDC estimates that between 41 million and 84 million cases of 2009 H1N1 occurred between April 2009 and January 16, 2010. The mid-level in this range is about 57 million people infected with 2009 H1N1.

# CDC estimates that between about 183,000 and 378,000 H1N1-related hospitalizations occurred between April 2009 and January 16, 2010. The mid-level in this range is about 257,000 2009 H1N1-related hospitalizations.

# CDC estimates that between about 8,330 and 17,160 2009 H1N1-related deaths occurred between April 2009 and January 16, 2010. The mid-level in this range is about 11,690 2009 H1N1-related deaths

In the last 10 years the seasonal flu has killed on average 36,000 Americans. The numbers above are just for H1N1, and are on top of  seasonal flu numbers (although I have not seen any final numbers on the seasonal flu yet).

So the net effect of H1N1 was to give us an especially bad flu season, but not the worst-case pandemic that was feared. It should be noted that seasonal flu kills mostly those >65 years old, while the H1N1 killed disproportionately those under 65, and also was more fatal to pregnant women. Raw numbers do not reflect this difference.

How about the GBS fears? Cases of GBS were carefully tracked by the CDC and in other countries and there was no increase in GBS associated with the H1N1 vaccine.

While cases are dwindling, the H1N1 pandemic is not quite over. It may be burning itself out, but cases are on the rise still in Africa. This leaves open the possibility that it could come back around. We have already had two waves of H1N1, and a third wave is possible. Further, it is the later waves of such pandemics which may be the most deadly. There has been a new mutation identified in a Mexican patient – and that is the concern, that the virus will mutate to a more virulent or contagious form before it comes back around. It is also possible that this strain of flu will simply combine and synchronize with the seasonal flu.

Thankfully, the H1N1 pandemic was a bit of an anti-climax. While it did bring a particularly bad flu season, it was toward the mild end of the spectrum of predictions. But also, all the fear-mongering about the flu vaccine also fizzled. The vaccine was safe and effective and served to blunt the effects of H1N1.

We will continue to track H1N1 as it may have another act to play.

Addendum:

After I posted the blog the representative from the CDC I had left a message with got back to me, just to confirm my reading of the stats.

The figures posted above are the hospitalizations and deaths from H1N1 alone, but essentially there were negligible cases of seasonal flu this year. This is still a big mystery – we were expecting H1N1 + seasonal flu, but the seasonal flu never showed.

Speculations as to why: high vaccination rates and high rates of compliance with good hygiene and people staying home if they were sick. There is also speculation about the H1N1 “crowding out” the seasonal flu strains, but this is not an established phenomenon.

The bottom line is that the flu is unpredictable – chaos theory in action. It will probably take a year or two to sort out why things happened the way they did.

A Utah company, Manna of Utah, is planning on building a plant in Odessa MO that will, among other things, build generators for home use. I wrote recently about another home generator company, Bloom Box, cautioning against accepting corporate hype at face value. Bloom Box appears to be a legitimate generator, surrounded by some misleading hype. But the generators promised by Manna of Utah seem to take the company name seriously, promising energy from heaven.

The generator they plan to build was designed and patented by another company, Maglev Energy, Inc. They claim to be able to generate electricity with magnets. Here is their description of their technology:

A running prototype using a new way to control attract – repel forces generated by permanent and electromagnet interactions.  Our unique configuration and intellectual property manipulates these forces to apply its product towards useful work. With chip technology, laser measuring devices, and MagLev Energy, Inc. (MEI) developed proprietary algorithms, this prototype produces clean, renewable, and better power conversion ratios than fossil fuels.

Most skeptics should instantly recognize this description as an utter scam – we are in Dennis Lee and Orbo territory here. You simply cannot generate free energy by cleverly interacting magnets. This seems to be the perpetual free-energy deception – whether self-deception or conscious fraud.

Notice the attempt to dazzle with technology terms – wow, they use chip technology and lasers. That space-age (i.e. 1960s) technology.

They further claim that their generators use less fossil fuel than conventional generators – “or no fuel at all.” What seems to be the scam here is that they have a fancy generator they claim is more fuel efficient than a typical generator. This in itself is not an amazing claim. Generators can burn fossil fuel in an engine that uses the energy to rotate magnets inside a coil that generates an electrical current. There are cheap and basic generators and more sophisticated and expensive generators. Building an elaborate generator that shaves off a few percentage points of energy loss is nothing new or amazing.

Free energy scam often use conventional generators as a bait and switch. They produce a fancy looking generator that burns gasoline (or some other conventional fossil fuel) and claim a higher efficiency than what you can buy at Home Depot. But then they claim that the same technology that provides an incremental increase in efficiency can be extrapolated to produce energy with less and less fuel, until you have a device that uses no fuel at all. They can then show investors and politicians their conventional generator to back up their claims – hey, it’s actually making electricity. And of course they have a “prototype” of the free-energy version (which just needs a couple of tweaks).

There is of course the pesky problem of thermodynamics. You cannot make energy from nothing – there is no free lunch. Current generator technology is pushing up against the barrier of efficiency, and any gains at this point are going to be minimal and diminishing – approaching 100% efficiency asymptotically but never reaching it. The first law of thermodynamic says you can never surpass 100% efficiency (sometime called “over unity”), and the second law of thermodynamics says you cannot reach 100% efficiency (there is always something lost to entropy).

Maglev Energy promises consumers:

Reduction or elimination of home power bills – Using conventional fuels, an MEI generator will reduce home electric bills by 50% or more. When coupled with solar or wind, power bills can be completely eliminated.

Sure – burn fossil fuel and make your own electricity and you will reduce your electric bill. Duh. (That is the Bloom Box model.) But is it cost-effective? And where are you getting the fuel from. If you have natural gas being pumped into your house maybe you can decrease your electric bill while you increase your gas bill. Or will you need to bury a huge tank in your yard?

The last line is classic – “coupled with solar or wind” – right – and that doughnut is “part of this nutritious breakfast.” Of course, you could just install wind or solar, which themselves would have to be analyzed for cost-effectiveness.

The public’s attention has been focused recently on the monetary and environmental cost of energy, and “renewable” energies is a hot buzzword. It is no surprise that we are seeing an explosion of companies looking to make money off this fascination. We may be in the midst of an energy scam bubble.

Here’s a tip for the media – get a clue. The information is out there, just exercise some Google skilz before writing that gullible report on the latest scam.

And here’s a tip for politicians and investors – get a clue. Consult with an actual scientist before investing in the latest free-energy con. Politicians in Utah and Odessa are hoping to gain attention for being so environmentally responsible and forward-looking. But instead they will simply be the targets of a round of ridicule from those with a clue.

Controversies in science are fun, and the spectacle of such controversies being worked out by competing groups of scientists is a wonderful way to learn about the process of science. But as science progresses, we hope to occasionally resolve controversies and come to a reasonable consensus.

One such controversy that I have been following is the question over what killed the dinosaurs, and much of other life on earth, 65 million years ago. The two leading contenders were an asteroid impact at the Chicxulub crater near Mexico, and volcanic eruptions at the Deccan trap in India. Now a new review of the literature has resulted in a solid consensus supporting the asteroid theory.

Actually, the consensus is somewhat of an anti-climax in that this consensus has been slowly building for years. In recent years the vast majority of scientists already agreed on the impact theory, with just a handful of holdouts rooting for the volcano alternative. So this latest report is no surprise.

In fact, this is often how such things will play out. It would be premature to try to impose consensus on a controversy when the controversy is still raging and the data is not yet definitive. On the other hand – why bother formalizing a consensus that already exists de facto?

In this case, at least, while there was a solid consensus, there was still a robust minority opinion and new data had been coming in fairly quickly. So it seemed like a good time to step back, take a thorough look at all the evidence, and see where the science really is. In this case, a thorough review of the evidence strongly supports the impact theory.

The biggest piece of evidence is that there is a layer of debris spread around the earth. This layer contains iridium, which is more common in asteroids than the earth’s crust. It also contains things like shocked quartz, which is created only during a sudden violent impact. There are also spherules – melted rock that hardens into spheres as it rains back down onto the earth.

Moreover, this layer varies in thickness around the world, pointing like a bull’s eye to Chicxulub. But most importantly, when you look at those layers that are about half-way around the world from Chixculub, you find nicely organized debris layers with a sharp demarcation of dinosaur fossils. Below the line – dinosaurs. Above the line – no dinosaurs. Get too close to the impact and the layers are jumbled by the impact itself. Get too far away and they are too thin to separate out the fossils nicely. But at the perfect distance, the layering becomes clear.

The consensus also dispenses with some of the objections. The timing of the mass extinction does line up with the impact. And the global effects of the massive volcanoes at the Deccan traps were small and short-lived – not enough to explain the mass extinction.

I wonder if this consensus will have any effect on those few remaining holdouts. I also wonder if it will affect future media reporting (probably not). One of my peeves of science news reporting is that the media will report a science news story by a scientist in the small minority as if it represents the new or consensus opinion. So whenever the volcano advocate published a study, the media declared that the impact theory was being rejected – not quite.

The same is happening with the dino-to-birds theory – this is by far the consensus opinion. But a few holdouts grab headlines occasionally and get the media to declare that the birds from dinosaurs evolution story is in doubt. It’s the journalists’ job to put the minority opinion in context, and they rarely do, which is irritating. The public is left confused by each new headline that seems to contradict the last.

And that may be the biggest benefit of such a consensus – if we can get the word out, it may help to make sense of the science to the public.

Since the discovery of magnetism, using magnets and magnetic fields has been a popular subject for quacks and charlatans – starting with Anton Mesmer and his “animal magnetism.” Recently there has been a resurgence of dubious magnetic devices for arthritis, pain, injuries, and other uses.

But today I am writing about the legitimate science of using magnetic stimulation for therapeutic effects. The brain is both a biochemical organ and an electromagnetic organ. Until recently our attempts at altering the physiology and function of the brain have focused on pharmacology – mainly either increasing or decreasing the action of specific neurotransmitters. This is an effective paradigm for seizures, preventing migraines, and treating pain. It has also been the approach for treating psychiatric disorders, with clear effects for psychotic symptoms, like those caused by schizophrenia, and also anxiety, eating disorders and severe depression. The effectiveness of pharmacological treatments for some psychiatric indications, however, remains marginal and controversial, for example for mild to moderate depression.

Because the brain is also an organ that interacts with the environment, there are also several specialties dedicated to addressing psychological concerns with environmental treatments – cognitive behavioral therapy, for example.

Electrical/magnetic interventions, however, have been scant, only recently getting significant attention. The only such intervention I can think of before the last decade was electroconvulsive therapy (ECT) for depression. It was observed serendipitously that some patients with severe depression and epilepsy would have relief of their depression following a seizure. This lead to the initial crude ECT treatments, inducing whole brain seizures. Later sedatives and paralytics were added for patient safety and comfort (avoiding the “One Flew Over the Cuckoo’s Nest” scene). ECT has been further revised to only induce seizures in one hemisphere, and recently using magnetic rather than electrical stimulation. While much safer and more effective, ECT is still a very crude intervention.

There are currently two electrical-based neurological treatments that are FDA approved. The first is a vagal nerve stimulator for refractory epilepsy. This uses an implanted stimulator outside the brain to stimulate through the vagal nerve and disrupt the synchronized firing of neurons that begin a seizure. This reduces, but does not eliminate, seizures in some patients and may reduce the need for multiple medications.

The second is implanted electrodes for Parkinson’s disease. These electrodes are implanted directly in the brain, in one of the structures of the basal ganglia, and produce steady stimulation to alter the action of the basal ganglia circuitry. This can be useful in decreasing tremor and rigidity in Parkinson’s disease, and again may reduce but not eliminate symptoms and reduce the need for medication.

These two interventions are interesting, but still fairly crude. We are starting to target specific brain regions with specific frequency and intensity of stimulation, but the potential remains for far greater precision and control. For example, research is underway to develop computer chips that contain embedded neurons that will hopefully be able to release inhibitory neurotransmitters directly a the time and location of the start of a seizure.

The new treatment represents yet another approach to using electromagnetism to affect brain function – the use of transcranial magnetic stimulation (TMS). TMS today is used for research – at different frequencies TMS can either induce or inhibit the activity in a focused part of the brain, and the results can be studied to figure out what that part of the brain does.

There is already published research looking at the effects of different frequencies of TMS on the excitability of brain regions during a migraine. A migraine is, in some ways, like a seizure – it is a neurological event involving abnormal activity in certain brain circuits (the trigeminovascular reflex, for example) and also involving hyperexcitability (leading to central sensitization) of certain populations of neurons. This leads clinically to hypersensitivity to sound, light, smell, and touch – which can both trigger and exacerbate a migraine.

The new study, soon to be published in Lancet Neurology, is a placebo-controlled pilot study using the frequency of TMS that prior research suggested would decrease the excitability of neurons during a migraine. The study used a hand-held device that a migraine sufferer can place at the back of the head and activate at the beginning of a migraine. The study showed a 40% pain free result at 2 hours – which is a clinically significant result, and a greater response at 2, 24, and 48 hours beyond the placebo group.

Incidentally, this treatment may be easy to blind as the patient uses what is essentially a black box. They press the button and have no way of knowing if a real TMS is being given. I have not seen the full report yet – so I don’t know if the placebo group devices gave no magnetic field and if that can be detected by users. Alternatively, the control device could give a non-therapeutic magnetic field as an active control.

This is preliminary research, and larger, more rigorous follow up studies need to be done. But it is highly plausible that this kind of treatment could provide a way for migraineurs to “turn off” their migraines by inducing inhibition through TMS in the hyperexcitable neurons that trigger and propagate a migraine. Side effects should also be minimal. We should not take safety for granted, however, and of course studies will have to follow patients to make sure there are no unintended consequences (sedation, cognitive impairment, or seizures, for example).

TMS has tremendous potential, as it does not require any implantable device – the fields can be induced from the outside. And I am encouraged that they were able to design a hand-held device capable of delivering an effective TMS pulse. Frequency, duration, intensity, and location of stimulation can all be varied in order to theoretically target different symptoms and conditions. We may be seeing the beginning of a new therapeutic paradigm in neurology.

One of the basic principles of science-based medicine is that a single study rarely tells us much about any complex topic. Reliable conclusions are derived from an assessment of basic science (i.e prior probability or plausibility) and a pattern of effects across multiple clinical trials. However the mainstream media generally report each study as if it is a breakthrough or the definitive answer to the question at hand. If the many e-mails I receive asking me about such studies are representative, the general public takes a similar approach, perhaps due in part to the media coverage.

I generally do not plan to report on each study that comes out as that would be an endless and ultimately pointless exercise. But occasionally focusing on a specific study is educational, especially if that study is garnering a significant amount of media attention. And so I turn my attention this week to a recent study looking at acupuncture in major depression during pregnancy. The study concludes:

The short acupuncture protocol demonstrated symptom reduction and a response rate comparable to those observed in standard depression treatments of similar length and could be a viable treatment option for depression during pregnancy.

Plausibility

The study compared acupuncture designed specifically to treat depression, and in fact tailored to the individual patient, according to principles of Traditional Chinese Medicine (TCM). This was compared to two control groups – a control acupuncture that was not specific to depression and massage. The comparison to massage was obviously not blinded and therefore, in my opinion, of very little value as depression is highly susceptible to non-specific therapeutic effects and both interventions – acupuncture and massage – would be likely to create such non-specific effects.

The interesting aspect of this study is the comparison between treatment acupuncture (targeted for depression) and control acupuncture (not targeted for depression). The purpose of the study was to control, as much as possible, for any other variables so as to determine if the underlying TCM principles have any validity – does it matter where the needles are placed?

We can really only put this study into context if we first consider the prior probability of this claim. I would argue that there is already a large body of acupuncture research that collectively shows needle placement as a variable has no effect on clinical outcome. This one study does little to alter the balance of that evidence.

Further, from a basic science point of view, the TCM principles have essentially no plausibility. The underlying theory is that there is an undetected life force (chi) that is partly responsible for health and illness, that acupuncture needles placed in specific acupuncture points alters the flow and strength of this energy, resulting in a clinical outcome. Chi has no existence in science, however. Vitalistic philosophies such as chi were discarded over a century ago as both unnecessary and without any empirical foundation.

Any modern attempts to explain acupuncture effects with known physiological phenomena might explain non-specific needling effects, but cannot explain any differences due to needle placement, and do not provide any explanation for the location of alleged acupuncture points.

Therefore, given the extremely low prior probability of the claims of this study, nothing short of a large rigorous and replicated study would alter our assessment of validity of acupuncture as a specific intervention.

The Current Study

This new study, published in the Obstetrics and Gynecology, is not of sufficient quality to justify the conclusions of the authors. The authors did do a decent job of trying to rigorously control the comparison between the two acupuncture groups. Subjects were blinded to which group they were in, as were those evaluating the outcome. Standard depressions scales were used. They even made a reasonable attempt to blind the acupuncturists, using a novel method (to my knowledge).

They had experienced acupuncturists design a treatment and control acupuncture regimen for each subject, and then had a “junior acupuncturist” (less than two years experience) perform the treatment without being told which one they were giving.

This, in my opinion, in the crux of the methodology – were the treating acupuncturists properly blinded. The study authors took the very useful step of assessing the degree of blinding of the acupuncturists and the subjects. Unfortunately for the validity of the study, they found that the treating acupuncturists were significantly more likely to have positive expectations for the treatment group than the control group – so their blinding methods failed with respect to the treating acupuncturists. The study was therefore, at best, single blinded. Test subjects did not have any significant difference in expectations.

Because depression is so amenable to non-specific therapeutic effects, the expectations of the treating acupuncturist can plausibly have had a significant effect on the final outcomes. This is the primary weakness of the study – but there are others worth mentioning.

The author also, for some reason, did not stratify the test subject according to race, and there turned out to be significantly more African Americans in the control acupuncture group than the treatment group. Cultural beliefs can have a significant effect on responses to different kinds of placebos, particularly needles. This is therefore a potential, if unknown, confounder.

The results were also not impressive. The study used the Hamilton Rating Scale for depression:

Interpretation of Hamilton Rating Scale for Depression scores is as follows: less than 7, nondepressed; 8–13, mild depression; 14–18, moderate depression; 19–22, severe depression; more than 23, very severe depression.

At 8 weeks the control acupuncture groups has about a 9 point drop in the scale, while the treatment acupuncture group dropped 11.5 points. On this scale that is a modest clinical effect. There was also no difference in remission rates among the three groups. In addition this was a relatively small study (141 treated in total, divided among the three groups) with a 23% drop out rate.

Conclusion

Therefore we have a small and improperly blinded and randomized study showing a modest clinical effect. This does not significantly alter the low prior probability of a treatment effect from needle placement.

This study should also be considered in the context of other trials looking at acupuncture and depression. This very recent Cochrane review concluded:

We found insufficient evidence to recommend the use of acupuncture for people with depression. The results are limited by the high risk of bias in the majority of trials meeting inclusion criteria.

Specifically – there was no difference between verum acupuncture and sham acupuncture in the clinical trials reviewed.

Given the low plausibility and overall negative character of the clinical evidence, it is reasonable to conclude that no further research into acupuncture for any indication is warranted. However, acupuncture is a modality with dedicated practitioners (acupuncturists) and proponents (by contrast, for example, there is no medical specialty dedicated to a particular drug – there are no penicillinists). And therefore it is likely that further research will be conducted.

In that event, given existing research, it would be useful to conduct only highly rigorous trials, using sham and/or placebo acupuncture (where the needle or fake needle does not penetrate the skin) with adequate blinding. Such trials would need to be large with consistent replicated positive results in order to have sufficient weight to overturn the current mass of basic and clinical evidence.

The Diagnostics Statistical Manual for Mental Disorders, a much maligned document, is in the midst of its fourth major revision (the DSM-IV will be replaced by the DSM-V). This process has been going on for over a decade. The revisions are now being made public in order to have a two year period of public comment and debate about the details of the revisions.

This has led to a new round of criticism of the DSM, and through it psychiatry, from those who either do not sufficiently understand, in my opinion, the nature of psychiatric diagnosis, and from those who are anti-psychiatry because of ideology (Scientologists, for example).

At the extreme end of criticism are those who deny the very existence of anything that can be called mental illness. I have already dealt extensively with their arguments, and won’t repeat them here. But even those are not so extreme fall into some of the same logical fallacies when criticizing mental diagnoses. Recently George Will, for example, wrote an editorial which I think confuses medical diagnoses with taking moral positions (I will get to his commentary below).

Diagnosis in Psychiatry

I do acknowledge the extreme difficulty of establishing discrete diagnoses in psychiatry. The brain is the organ of mood, thought, and behavior, and it interacts in complex ways with the environment. So it is very difficult to tease apart those manifestations that should be considered a symptom of dysfunction from those that simply represent the range of normal variation or the effects of the environment.

Further, when there is demonstrable pathology we tend to think of those disorders as neurological, not psychiatric – even when they have overtly psychiatric manifestations (mood, thought, and behavior). If someone becomes psychotic (develops delusions and hallucinations) and is found to have a brain tumor, most people have no problem understanding that the tumor caused the psychosis – that this is a disease that needs to be treated. However, if another person becomes identically psychotic and no underlying pathology is found, suddenly this is a psychiatric disorder (not a neurological disease) and many people wring their hands about whether or not it is a real disorder, how to define it, and if it should be treated at all.

The challenge of psychiatric diagnosis also suffers from the fact that mood, thought, and behavior exist on a continuum – a Bell curve of variation. So there is often a demarcation problem – between healthy variation (the term “normal” is too problematic to use effectively), and mental disorder. Take any mental trait, such as anger. Some people are more angry than others. What if someone had no control over their anger and were perpetually on the verge of rage – triggered by the slightest perceived offense? It seems reasonable that at some extreme of anger we can meaningfully call this a mental disorder and explore ways to treat it. But there is no sharp line between healthy anger and a dysfunctional loss of self control.

This, of course, is the exact challenge of the DSM – coming up with reasonable criteria to designate when there is a disorder and some scheme of categorization. The definition of “disorder” that guides this process is the lack of a trait or ability usually possessed by people that leads to a demonstrable harm (like self-control).

Psychiatry also has a lot of historical baggage to contend with. In the dark ages of psychiatry, which we are barely out of in historical terms, diagnoses were not cleanly separated from the current fashionable moral judgments of the time. And so homosexuality was considered a mental disorder for a time. Treatments were likewise crude, even cruel. But it is a fallacy to blame the modern profession of psychiatry for the sins of the past – sins from which they have already redeemed themselves. It must also be noted that psychiatry was largely reformed from within.

Mental Illness and Morality

In his editorial, George Will argues that the DSM, including many of the new diagnoses being contemplated, represents medicalizing character traits, in order to exempt them from moral consideration. He commits many of the errors of mental illness denialists, however, in forming his arguments. He writes:

Today’s DSM defines “oppositional defiant disorder” as a pattern of “negativistic, defiant, disobedient and hostile behavior toward authority figures.” Symptoms include “often loses temper,” “often deliberately annoys people” or “is often touchy.” DSM omits this symptom: “is a teenager.”

Clearly Will thinks that a “normal” teenager might earn for themselves the label of “oppositional defiant disorder” – ignoring the crucial aspect of diagnosis that these traits must exist to an extreme degree, sufficient to cause demonstrable dysfunction. Therefore your average disobedient teenager would not (should not) be diagnosed. But a child who was unable to function at school because of frequent hostile disobedience might.

My wife, who is a counselor, actually worked with oppositional defiant children for a few months (those severe enough that they were enrolled in a special school) – they quickly burned her out (quite a feat, as she is a very tolerant person) and she decided to change jobs. There is no way to quantify severity of a mental disorder like this, and so some judgment is always required. But when you see the extreme cases you know what oppositional defiant disorder means, and you won’t confuse it for average teenage behavior.

He continues:

This DSM defines as “personality disorders” attributes that once were considered character flaws. “Antisocial personality disorder” is “a pervasive pattern of disregard for . . . the rights of others . . . callous, cynical . . . an inflated and arrogant self-appraisal.” “Histrionic personality disorder” is “excessive emotionality and attention-seeking.” “Narcissistic personality disorder” involves “grandiosity, need for admiration . . . boastful and pretentious.” And so on.

If every character blemish or emotional turbulence is a “disorder” akin to a physical disability, legal accommodations are mandatory. Under federal law, “disabilities” include any “mental impairment that substantially limits one or more major life activities”; “mental impairments” include “emotional or mental illness.” So there might be a legal entitlement to be a jerk. (See above, “antisocial personality disorder.”)

The DSM actually differentiates between a personality “trait” and a personality “disorder”. A disorder is no mere “character blemish” – it is a gross disfigurement. This is a crucial concept missing from Will’s editorial and highlights the danger of criticizing an entire profession without sufficient expertise to do so. Also, the personality disorders are considered the least “illnessy” of the mental illnesses. In fact they are described in the DSM and are part of psychiatric assessments so that their traits can be differentiated from more hard core mental illnesses, like schizophrenia or bipolar disorder.

Will continues with this fallacy a bit more, then turns to a new one:

Extremely irritable or aggressive children are frequently diagnosed as bipolar and treated with powerful antipsychotic drugs. This can be a damaging mistake if behavioral modification treatment can mitigate the problem.

Does Will really think he has a better grasp on the evidence for the relative safety and effectiveness of medication vs behavioral therapy for a variety of mental disorders than trained experts? But that aside, this hits upon one of the features of the proposed DSM-V revisions (albeit controversial even within psychiatry). New diagnoses were carved out in the DSM-V for the stated purpose of differentiating them from more severe disorders that are more likely to be treated medically.

Will links to this article in the Washington Post (apparently the spur for his editorial) which states:

Others expressed concern about the proposals to create new conditions such as “temper dysregulation with dysphoria,” or TDD. Supporters say it is intended to counter a huge increase in the number children being treated for bipolar disorder by creating a more specific diagnosis, though critics argued that it would only compound the problem of overtreatment.

I don’t know what the net effect will be of making a new category of TDD – it seems to be a matter of debate among those revising the DSM. But at least Will should understand and acknowledge that stated purpose by supporters – to create a less severe diagnosis and decrease the number of people who will quality for the more severe diagnosis and therefore likely get treated. Will assumes that labels lead to increased treatment, but the opposite may be true depending on how they are applied. At the very least this topic is more complex than Will’s simplistic formulation.

Finally we get to the core of Will’s point:

Furthermore, intellectual chaos can result from medicalizing the assessment of character. Today’s therapeutic ethos, which celebrates curing and disparages judging, expresses the liberal disposition to assume that crime and other problematic behaviors reflect social or biological causation. While this absolves the individual of responsibility, it also strips the individual of personhood and moral dignity.

This one paragraph could be the subject of a separate post, but I will try to summarize my points quickly. First, it must be realized that within medicine it is absolutely necessary to focus on curing and to “disparage judging”. Physicians need to be non-judgmental toward their patients, and should never impose their morality, religion, or politics onto their patients. That is a core principle of medical professionalism.

I will give Will the benefit of the doubt and assume he is not denying the necessity of this professional ethic. Rather, he seems to be lamenting the extension of this attitude into the realm of broader society – claiming that it is a “liberal disposition.” I don’t want to venture into a political argument on this blog, but I will just say that I see his point and will assume for the sake of argument that it is part of liberal political philosophy, in the name of social justice, to emphasize the situation and conditions that lead to individual behavior. Meanwhile, conservative philosophy emphasizes individual responsibility. This appears to be the lens through which Will is viewing the DSM.

But I think it is fallacious to criticize the DSM for trying to understand the human condition, simply because some may use that knowledge to bolster a political position with which Will disagrees. Rather, it would be more appropriate to simply argue that understanding the biological cause of behavior does not and should not absolve one of personal moral dignity or responsibility. Will instead has decided to attack the notion that behavior is biologically caused.

This relates to the deeper question of free will. Again, I will not delve into this complex issue, but briefly – if we take the premise that the mind is the brain, and the brain, as a materialistic physical entity, is deterministic, then we can conclude that all behavior is ultimately caused. Depending upon how one defines free will, it can therefore be argued that free will is ultimately an illusion as behavior is deterministic.

My take has been that, while this is true, we are still capable of making choices based upon internal reflection, and I call this free will (acknowledging that it is ultimately deterministic). But in any case, even those who deny the existence of free will acknowledge that we still need to have laws that hold individuals responsible for the choices they make. From a societal and legal point of view, we still need to act as if we possess free will – because those laws and moral boundaries are part of the environment that feed back on our behavior.

Will is in the curious position of making the same mistake that many of the liberals that he criticizes make – denying the underlying science rather than the inappropriate moral connection. It is better to assess the science for its own sake, and in this case not just the basic science but the medical utility of the DSM – and then separately argue that simply because a behavior can be meaningfully called a disorder that does not mean we do not hold people responsible for their behavior.

Admittedly this creates another demarcation problem – because we do draw a fuzzy line beyond which we mitigate guilt due to mental illness. This is now a legal question – the insanity defense. We recognize that someone’s mental function can be so compromised that they should not be held responsible for their behavior while in that state. There are established criteria for such a defense, and like many legal criteria they are complex and blurred at the edges, but can be reasonably applied in the real world. It would be a slippery slope argument to imply that any acknowledgment that extreme mental illness mitigates guilt leads to the medicalizing of all morality.

Conclusion

The issues raised by Will and other critics of the DSM and its current revision are complex. There may be problems with the current revisions – I would expect any such process to be messy and involve many controversies and trade offs. But I don’t think that Will and others with similar criticisms are hitting upon the true complexities of making mental diagnoses.

Most often criticisms of the DSM stem from looking at the list of symptoms that comprise the diagnostic criteria for a particular diagnosis and then not putting them into their proper context. This results in confusing healthy human variation with the extreme traits that constitute a disorder.

I am often asked if skeptics and skeptical organizations should undertake first-hand investigations. Of course, it depends upon what your goals are. But I think the question can be re-phrased to mean – is there any value or benefit to first hand investigation, and to this the answer is a definite “yes.”

But this is not to denigrate the value of skeptical review from the comfort of your computer chair. This kind of activity has sometimes been referred to as “armchair skepticism” – meant to be derogatory. While I see the value in going out into the field, armchair skepticism has a valuable and complementary role to play.

In fact, these two activities mirror what real scientists do, and are roughly analogous to peer-review vs experimental replication.

The community of scientists keep each other honest, and keep the process of science grinding forward, in various ways – only one of which is going into the lab to replicate a study or do follow up research. When a colleague publishes a paper, or presents a paper at a meeting, his colleagues provide analysis and criticism. Ideas are examined for logic, internal consistency, and plausibility. Other options, perhaps neglected by the researcher, are explored. And existing research, perhaps not taken into account by the researcher, is brought up and discussed.

This feedback is provided without ever doing any actual investigation. When skeptics perform the exact same service to paranormal or fringe claims, this should not be denigrated at all, but seen as providing in our area of expertise the same kind of analysis that scientists provide in theirs.

This “peer-review” takes several forms. First, the term “peer-review” is often used to refer to the formal process of reviewing a paper that has been submitted for publication. I am not referring to this formal peer-review (which I do not think has any analogy in skeptical activity), but rather to the informal peer-review that collectively refers to all the efforts of the scientific community to hammer errors and flaws out of scientific thinking.

Informal peer-review has various manifestations, all of which have analogies in skeptical activism. For example, scientists will often dissect a specific published paper, analyzing it for weaknesses of methodology, strength of the outcome, how well the authors interpret their own findings, and putting it into the context of plausibility and other published research. This analysis may be published as a letter or commentary in the same journal as the original study, or incorporated into a talk at a meeting. Skeptics will often do the exact same thing, but these days published as a blog or article in the skeptical literature.

Scientists will also publish systematic reviews or topic reviews, reviewing all the published evidence and arriving at a bottom-line assessment of the state of the science. Skeptics do this as well. This activity does involve “research,” but not laboratory or field research – rather it involves researching the literature. It is getting easier and more viable to perform this activity sitting in front of a computer with internet access, as there are online libraries of published research, and many journals and news outlets have online versions.

Depending upon the topic and the depth of one’s investigation, it may be necessary to venture into a physical library, but this is getting less and less necessary. This is the level of research one would do when writing a book, but not for a daily blog post.

Armchair skeptics therefore provide a valuable service, similar to the activity of working scientists. We can analyze specific claims, topics, or published research for quality, plausibility, and historical and scientific context. We can then tailor our writing to communicate with our colleagues, the public, or both simultaneously. We can also provide reference material (like The Skeptic’s Dictionary), which fills the role of a science textbook or reference website.

While I am a strong advocate of armchair skepticism, if you have the opportunity to go into the field and do first-hand investigation, you will likely find the experience very illuminating. Theory and book-learning does only go so far, and there are aspects to paranormal investigations that you would simply not imagine until you are there to see it first hand.

I and my colleagues have performed a number of investigations – mostly haunted houses, but also EVP, channelers, exorcism, and psychics. Most of these were with other (less-than-skeptical) groups. What was always very striking was how unimpressive the paranormal investigators or claimants were. We always gave them more credit than they deserved, and were surprised at how easy it was to analyze their evidence.

For example, when we investigated a channeler in Connecticut who claimed to channel the 600 year old spirit of a man from Nepal, I was prepared to have the Nepalese analyzed to see if it was modern or appropriate to the claimed time period. However, the channeler did not speak any dialect spoken in Nepal, just English with a cheesy regional accent (it sounded Indian to me).

We also went on an EVP (electronic voice phenomenon) recording session with some local ghost-hunters. EVP is basically an exercise in audio pareidolia – listen to static long enough and you will make out words. We sat in the attic of an allegedly haunted restaurant. Even though it was relatively quiet in the location, I was struck by how much background noise there was. When you listen carefully, you can hear voices in the street, the rumblings of any building, and blowing of the fan, and other noises of unclear source. It was far more noisy than I had anticipated, providing a rich source of raw material for later imaginative listening.

I also actually sat through hours of recorded exorcisms. This is not an activity I am eager to repeat, but it certainly gave me a more thorough perspective on what goes on in such exorcisms – basically nothing. They are incredibly boring non-events.

I will also relay the experience of Susan Blackmore, a former ESP researcher who eventually gave up ESP research as fruitless. She noted that there is only so much you can infer about the quality of another researcher’s methodology from the published report. When you actually go into their lab and examine the methods first hand, you get a much better idea of the quality, and may identify flaws that were not apparent from the published description.

And of course, Joe Nickell, who does investigations full time, has many tales of paranormal claims and stories that could not be definitively resolved without on-the-site investigation.

Both armchair skepticism and first-hand investigation are important to skeptical activism. They are complementary, each filling different needs. Both also are analogous to activity that working scientists perform in the process of peer-review, new investigations, and replicating previous research.

In the last decade or so I feel that the skeptical community has honed its ability to perform meaningful peer-review of paranormal claims, and communicate the results of that review to the public. It is also my sense that our overall activism would benefit from increased efforts to perform more first hand investigations.

I would even go beyond replicating the typical haunted house investigation, and do some real hypothesis testing. This of course takes time and resources, but would be well worth it.

It’s been a bad year for homeopathy, and it’s still February. The 10^23 campaign has been making a proper mockery of the magical medicine that is homeopathy, capped off with their mass homeopathic “overdose.” In Australia skeptics have been taking homeopathic websites to task for making unsupported health claims. And in the UK there has been increasing pressure to question NHS support for homeopathy – most recently the House of Commons Science and Technology Committee concluded that homeopathy is nothing more than an elaborate placebo and the NHS should completely defund and remove any support for homeopathy. This could be a death blow to homeopathy in the UK, and provide support for similar efforts elsewhere.

Last year was no better. Most memorable was this comedy sketch by Mitchell and Webb, who nicely skewered homeopaths and other cranks. When comedians are not ridiculing them, homeopaths were doing a fine job of lampooning themselves – the best is this video where Dr. Werner tries to explain how homeopathy works – pure comedy gold. Of course the best real explanation for how homeopathy works is here.

Even before the House Committee presented its final report, the embarrassing moments were being immortalized on YouTube, for example the head of a major UK pharmaceutical chain admitting that they market homeopathic products with full knowledge that they don’t work.

All of this has homeopaths a bit desperate, it would seem. They now realize that skeptics and scientists are starting to get traction with their criticism. This is good, because as I have argued before the more we get homeopaths and other pseudoscientists trying to defend themselves, the more they will do our work for us.

Thanks to commenter tl;dr for pointing out this video by homeopath, John Benneth. This is the best incoherent rant yet by a crank against skeptics. If I did not already know Benneth from his other videos, where he puts forward rambling technobabble trying to make homeopathy seem scientific, I could easily have believed this was satire. Benneth looks disheveled, distracted, and gets childishly sarcastic at one point. But that aside, the content of his rant is priceless.

Benneth decides to take on skeptics directly, and by name. He mentions Randi, Edzard Ernst, Simon Singh, Harriet Hall, Michael Shermer, and your humble servant (thanks for including me in such excellent company). He then proceeds straight to the logical fallacy aisle and fills his cart.

He does everything he can to smear our reputations – the video is mostly a giant ad hominem logical fallacy. He says of us:

Whose purpose is to destroy legal medical practice. They’ve made an industry out of libeling others and they’re getting sued for it.

He equates being sued for libel with lying, and mentions Singh and Randi specifically. Yes – being a public critic opens oneself up for being sued for libel as an intimidation and silencing tactic. In fact, this has gotten so out of control, especially in England, that the scientific community (such as this editorial in the British Medical Journal) have called for keeping libel laws out of science. Let us have open debate in the public interest – and not abuse the courts to silence critics.

Benneth misses the fact (or I suspect just does not care) that Simon Singh’s case is still ongoing, and that his criticism of the British Chiropractic Association was completely legitimate – in my opinion and that of many others. Also, while Randi was sued (for example, by Uri Geller) he won those cases. So Benneth seems to be following the strategy – sue someone for libel, then claim they are not legitimate because they were sued for libel – no matter what the status of the case. The accusation of lying is equivalent to lying, for the individual and all of their associates – for reference, see “witch hunt.”

But it gets much worse. Benneth says:

Their action’s like a bunch of terrorists spreading lies and trying to discourage anyone who wants to get legal medical treatment.

I see your ad hominem and raise you a straw man. Wow – the terrorist card. Nice. Of course, our criticism has nothing to do with discouraging people from getting legal medical treatment. Rather, we are trying to educate the public about the scientific basis for treatments that are available, and also to lobby for rational and science-based regulation. Benneth, it seems, is taking the “restraint of trade” tactic that worked for American chiropractors against the AMA. In fact, he characterizes what we are doing as “not legal,” – he is accusing us of actually breaking the law by criticizing his nonsense.

He then returns for some more ad hominem, saying:

None of these people I’ve named, Randi, Ernst, Novella, Singh, are medical practitioners.

Harriet Hall’s not a medical practitioner. Oh, she might have been a flight surgeon at one time, but she’s not now. They’re always retired people, or they’ve been disbarred or defrocked or something, you know they have had some problems in the past. They can’t make it as real doctors or real scientists so they make their livings now by criticizing the works of real practitioners and real scientists, and then they try to run of their business is support. That’s called interference with trade. It’s a crime.

Edzard Ernst is a Professor of Complementary and Alternative Medicine. He is widely published in the peer reviewed literature, including many reviews of homeopathy. He has, by all accounts, a successful and internationally regarded academic career.

Harriet Hall is retired, after a full career as a primary care doctor. She was never “disbarred” or “defrocked” (probably because she was never a lawyer or a priest) – she simply retired. She decided to remain productive in her retirement, and so spends some of her golden years educating the public about science and medicine.

I work with many physicians who have decided to spend time defending the standard of science in medicine and educating our fellow professionals and the public about the relationship between science and the practice of medicine. Most are either actively practicing doctors and nurses or retired professionals. Some, like me, are academics. We also work at times with scientists and educators in other disciplines – such cross-fertilization in science can be very fruitful. We come together over a shared commitment to logic and reason.

Benneth, while ironically accusing us all of actual libel, has decided to slander us by making the demonstrably false accusation that we are all “failed doctors and scientists.” And I wonder what “problems” he is referring to.  I suppose Benneth is used to just making up his facts to suit his needs. After all – he is a homeopath.

Benneth apparently did not do his homework before switching on the video camera, and had to add this caveat in the middle of his video.

I have been informed that Stephen Novella [sic], a notorious self proclaimed “skeptic,” homeopathy basher and professor of neurology at Yale, does indeed qualify as a practitioner. However, I question whether or not he is really a practitioner of medicine, or is simply listed as such for political reasons; why is he thrusting himself into the limelight to pass judgment and argue on another medical doctrine which he denies? His involvement in strange activities have little to do with his profession. A good practicing physician would not take such an extensive, rancorous and defamatory political position against another modality that has support in the material sciences, debating the heads of departments from other universities, such as Professor Ruston Roy of Penn State, Professor William Tiller of Stanford and Professor Iris Bell, MD of the University of Arizona, calling their conclusions “nonsense.” so I question whether he can take on the heavy responsibility of being a competent practicing clinical neurologist while racing around the country to appear on TV shows, pursuing such comparatively frivolous and defamatory activities as organized “skepticism,” (not Pyrrhic skepticism, which demands withholding judgment in lieu of man’s inherent agnosticism.) The man is bizarre. President and co-founder of the New England Skeptical Society (NESS), he hosts their podcast, “The Skeptics’ guide to the Universe,” writes a monthly column called “Weird Science” for the New Haven Advocate, writes a blog and contributes to others. He has also appeared on several television programs, including an [sic] crude cable TV program hosted by abusive magicians. So where he gets time to be a good practicing neurologist is questionable.

Cranks really do not like to be criticized, especially by an academic with some credentials. It really irritates them. Recently on this very blog, naturopath Christopher Maloney, responding to criticism of the lack of science behind his claims and practices, took a similar approach in the comments to this blog. He went as far as to accuse me of neglect for spending my time in skeptical activities.

Maloney and Benneth appear to be blissfully unaware of the academic lifestyle. I have many colleagues who spend more of their non-clinical time than I doing things like maintaining websites, writing textbooks, doing research, or engaging in other academic activities. It’s pretty much expected. I do teaching, writing, and some research as well. But I have decided to spend much of my spare time pursuing public science education and advocating for high standards of science in medicine. All of this is in addition to a full time clinical schedule. Such are the realities of an academic medical career.

Benneth and Maloney are only interested in making a cheap (and naive) ad homimen attack – which basically amounts to saying “shut up.” They cannot deal with the substance of the scientific criticism aimed against them and their beliefs, so they try to make it seem like the entire endeavor of criticizing pseudoscience in medicine is not legitimate. It’s all quite childish.

I also like how Benneth says that my “involvement in strange activities have little to do with his profession.”  “That,” as Yoda once said, “is why you fail.” Skepticism is essential to being a good clinician. A clinician must understand how to read and apply the scientific literature, and how to be wary of the mental pitfalls that tend to lead us astray. Being a good clinician is partly being a good investigator, a Sherlock Holmes of medicine – which has everything to do with skeptical philosophy. Benneth rejects skepticism and practices homeopathy – it is easy to see how these two things are related.

Sprinkled throughout the video is also Benneth’s claim, implied or direct, that homeopathy works. He makes the astonishing claim:

Nobody would practice homeopathy unless there was clear evidence, clear evidence that it worked.

This is naive in the extreme, and by extension would mean that every medical practice must work, or else why would people use it. I guess this means that the bloodletting that was practiced in the West for two thousand years must have also worked. Throughout the video he also presents text from published studies which presume to show that homeopathy works. But as usual he is cherry picking and misrepresenting the evidence.

A thorough review of the homeopathic literature shows a clear pattern of no effect greater than placebo. In a systematic review of systematic reviews, Edzard Ernst concluded:

In particular, there was no condition which responds convincingly better to homeopathic treatment than to placebo or other control interventions. Similarly, there was no homeopathic remedy that was demonstrated to yield clinical effects that are convincingly different from placebo. It is concluded that the best clinical evidence for homeopathy available to date does not warrant positive recommendations for its use in clinical practice.

But of course, Benneth thinks Ernst is not an authority, even though he has more than 70 peer reviewed published articles on homeopathy.

After reviewing the evidence and testimony on both sides, the Science and Technology Committee also agreed that there is no plausibility to homeopathy and the clinical evidence shows it is no better than placebo. This accords with my own reading of the literature. And let us not forget that there is, for all practical purposes, zero plausibility to homeopathy. You don’t have to be a clinician to understand this – homeopathy violates basic principles of physics, chemistry, and thermodynamics. Homeopathic preparations are often diluted beyond the point where there is any active ingredient left, and this fact cannot be rescued by any hand-waving arguments about nanobubbles and radio waves.

Conclusion

The cat is clearly out of the bag. Homeopathy is a 200 year old pre-scientific system of pure pseudoscience. Modern attempts to explain how it might work have failed, and the clinical evidence shows (no surprise) that it does not work.

The public has been largely unaware of these facts, thinking that “homeopathic” was equivalent to “natural” and that they were getting herbs or some plant-based treatment. Like any cult, information is the enemy of homeopathy. The more the public, and regulators, understand about homeopathy the more ridiculous it seems.

Homeopaths are now in the desperate situation of shouting “ignore that man behind the curtain.” They have decided to attack the messengers – skeptics. But in so doing they are just making the situation worse for themselves, as their attempts to explain homeopathy and discredit their critics are indistinguishable from drunken rants.

One of the strengths of the skeptical movement, as an intellectual community, is that we wrangle with important issues regarding the relationship between science and what people do and should accept as probably true. We deal with not only specific issues, but the bigger question of process. For example – how much weight should an individual give to any specific scientific consensus, and is this just an argument from authority?

This question has recently become central to the debate over climate change – one of those few scientific debates that fractures the skeptical community. We are fairly united when it comes to the question of ghosts, Bigfoot, and UFOs. But when certain topics come up, like climate change, there is disagreement over the meaning of consensus, what the consensus is, and the very definition of “skeptic”.

Consensus vs Authority

Deferring to the scientific consensus on a given topic is not the same thing as making an argument from authority – a logical fallacy to be avoided. The argument from authority essentially follows the pattern of concluding that a claim is true because it is being made by a person of some authority (scientific or otherwise). Most of us spend our childhood committing this logical fallacy – the right answer is whatever an adult says it is, or the teacher, or whatever the news reports “scientists” are saying.

As we mature and grow in personal knowledge we eventually cross a threshold where we feel confident relying on our own judgment, even to the point of rejecting authority. This seems to be instinctive for teenagers, and of course the rejection of authority simply because it is authority is an overcompensation. Ideally, as adults, we reach an equilibrium where we listen to authority, but understand its limits, and do not use authority as a replacement for independent thought.

As skeptics we have collectively tried to develop a nuanced and sophisticated approach to scientific authority, and many excellent articles have been written on this topic. Since we advocate rigorous and robust scientific methodology as the best way of understanding nature, we trust this process to some degree. We understand there can be fraud or sloppy studies, but generally if the research of others is all pointing toward one answer, we trust that research and its conclusions.

But science is complex, and few people can master more than a fairly narrow range of scientific expertise. And so outside our area of expertise (which is all of science for non-scientists) the best approach to take, in my opinion, is a hybrid approach – first, try to understand what is the consensus of scientific opinion. This is a good starting point – what do scientists believe, what do they agree on, and where is there legitimate controversy? How sure are they of their conclusions, and how strong is the consensus on any particular question?

But also, those interested in science will want to understand the evidence directly and how it relates to the consensus. But at the same time it must be recognized that a non-expert understanding of the evidence is a mere shadow of expert understanding. For example, I have read many articles about Archaeopteryx – a transitional species between theropod dinosaurs and modern birds. I can rattle off some of the anatomical details that mark Archaeopteryx as transitional – the presence of teeth and a long bony tail, for example. But there are details of anatomy that I cannot hope to appreciate, that require months or years of study and apprenticeship, and experience actually examining and describing fossils, of immersing oneself in the literature at the finest level of technical detail. And so ultimately I am trusting experts to interpret the fossil for me – not to mention to reconstruct the bones in the first place. I can only try to understand it on the deepest level I can.

What I conclude from this is that it is extreme hubris to substitute one’s frail non-expert assessment of a detailed scientific discipline for the consensus of opinion of scientific experts.

But there is still more complexity to this issue. First, the consensus of opinion is not always right – it is just usually right. So one can always think that for any particular question this is one of those rare times when the consensus got it wrong. Also, there is almost always a minority opinion among experts – the outlier who is an expert but who constructs the evidence in a different way. So the non-expert can always tell themselves that a particular scientist who is an expert agrees with their opinion. This is not very reassuring, because such minority opinions are in the minority for a reason, and generally turn out to be false. (Although they serve a very useful function in the process of debate and analysis that is science.)

Further, I would argue that there are skill sets that apply, at least to some degree, to just about any science. There is knowledge of scientific methodology and the pitfalls of pathological science. So it is possible to recognize pathological science even in a discipline in which one is not an expert. But even still such out-of-field critiques should be undertaken with extreme caution. The question is – is the criticism dependent upon a detailed technical knowledge of the field, or a recognition that some underlying assumptions and methods are wrong. Even in the latter case, it is good practice to check oneself with an actual expert, to make sure you are not missing something.

I offer as an example the recent criticism of evolutionary theory by non-biologists Fodor and Piattelli-Palmarini. P.Z. Myers explains very well where they went wrong – they make all the mistakes of not respecting a consensus or the limits of their technical knowledge outside their area of expertise.

Climate Change

Getting back to climate change, all of the complexities of assessing consensus are in play. Generally, non-experts tend to accept or reject anthropogenic climate change based upon their politics and world-view. That is a strong indication that most people are not assessing the science objectively, but are simply fitting the science to their ideology.

Don Braman, a faculty member of George Washington University and part of The Cultural Cognition Project, is quoted as saying:

“People tend to conform their factual beliefs to ones that are consistent with their cultural outlook, their world view,” Braman says.

The Cultural Cognition Project has conducted several experiments to back that up.

In the same report, Robert Kennedy Jr. is quoted as saying:

“Ninety-eight percent of the research climatologists in the world say that global warming is real, that its impacts are going to be catastrophic,” he argued. “There are 2 percent who disagree with that. I have a choice of believing the 98 percent or the 2 percent.”

That is a basic statement of acceptance of the scientific consensus. But Robert Kennedy is not always a fan of the scientific consensus – for example he rejects the scientific consensus on vaccines, choosing to believe that the consensus is a deliberate fraud (exactly what global warming dissidents say about the climate change consensus). This makes Robert Kennedy a hypocrite – he accepts the scientific consensus and cites its authority when it suits his politics, and then blithely rejects it  (spinning absurd conspiracy theories that would make Jesse Ventura blush) when it is inconvenient to his politics.

But Kennedy is not alone – this seems to be what most people do most of the time. In fact I would argue that we need to be especially suspicious of our scientific opinions on controversial topics when they conform to our personal ideology (whether political, social, or religious). That is when we need to step back and ask hard questions that challenge the views we want to hold. We also need to make sure that our process is consistent across questions – are we citing the scientific consensus on one issue and rejecting it on another? Are we citing conflicts of interest for researchers whose conclusions we don’t like, and ignoring them for researchers whose conclusions confirm our beliefs?

Skeptics

Being a skeptic is partly about wringing our hands and closely examining these very questions – especially as they pertain to our own beliefs. The question of scientific consensus is complicated, and my views on the topic have evolved over the years as I have discussed the issue with my fellow skeptics and tried to apply it to specific issues. It is an issue worth examining closely.

I have been following the story of the crazy libel laws in England, brought to public attention by the British Chiropractic Association (BCA) suing journalist Simon Singh because he dared to (correctly) state that many of their treatments are “bogus.”

In England (if I understand correctly, these laws apply only to England and not to all of the UK) when someone is sued for libel they bear the burden of proof that what they said was true. Further, the process is so expensive that it is easy for deep pockets to intimidate those with fewer resources into silence merely by the threat of suit.

Simon has bravely stuck with his suit, at great personal expense, largely to use it as a platform to lobby for rational libel reform.

There has been a positive update in the case itself. Originally it was judged that when Simon wrote that the BCA happily promotes treatments that are bogus, what he meant was that the BCA knows that their treatments are bogus. Therefore Simon has to prove that the BCA as an institution, and all of its members, believe their own treatments to be fake and ineffective.

This is an impossible standard, and clearly the case would be hopeless on those grounds. Simon was eventually granted the right to appeal that decision, and this appeal case is now ongoing.

As an aside, the BCA did a good job supporting Simon’s case when they defended themselves by providing evidence for their treatments. What they provided was a cherry-picked list of weak or irrelevant studies, showing all the more that their treatments are bogus. And by ignoring negative studies, one could reasonably make the argument that they know what they are doing – that they know their treatments are bogus.

In any case, We now learn from Jack of Kent ( a UK blogging attorney) that Simon has had a good day in court, and the judges seemed very favorably disposed toward his position. However, English courts are very conservative in that, even if the judges disagree with the previous decision, they may still be reluctant to overturn the lower court. They have yet to make their final decision.

Jack wrote of the case:

It had been thrilling to watch three of the country’s senior judges tear into the BCA case, even though it was sad that it had come this far.

Cranks rarely impress experienced judges, who understand something about the rules of evidence and logic (the Dover vs Kitzmiller trial is an excellent example of this).

I’ll  keep you updated as the trial proceeds. The bigger story, of course, is the attempts to reform English libel law. This is a free speech issue, and one that every skeptic and scientist should be concerned with.

I received numerous e-mails asking me to discuss the Bloom Box after it was featured on 60 Minutes this week. Energy production is a hot topic, which I think explains why this was such a big story. In reality, this is an interesting technology that will likely have useful applications – but it is not the green revolution.

The Bloom Box is essentially a generator – a type of fuel cell that is constructed of a stack of ceramic plates with different (secret) substances painted on either side. You feed fuel and oxygen in one end, and you get electricity out the other end.

I found it amusing how 60 Minutes tried to spin this into something more than it is – it’s a generator. The most likely fuel for the Bloom Box is natural gas, a fossil fuel. Natural gas is still somewhat abundant and cost effective, and there is already a distribution system for it. So in the end this is just another way to burn fossil fuels to generate electricity.

During the interview it was mentioned that you could also feed bio-gas from landfills into the Bloom Box, in which case it would be “carbon neutral.” Well – it is more accurate to say that the fuel source is carbon neutral – not the Bloom Box itself, which depends on whatever fuel you feed into it. It’s like saying a car is carbon neutral if you put biofuel in its tank – true, but this is not a feature of the car itself.

Biogas is a legitimate green technology – using microbes to make methane (primarily) from manure and waste. At present this represents a small fraction of our energy needs, but there is potential for significant expansion.

What I found very odd about the 60 Minutes interview is when Leslie Stahl asked the inventor of Bloom Box if one could feed “solar” energy into the Bloom Box, and he repeated, “solar” – as if confirming her statement, but this was followed by an abrupt edit. I get the sense he said something qualifying after that edit that we did not get to hear – especially since I don’t know what he could be possibly talking about. How can you feed solar energy (in what form?) into a generator that burns natural gas or some equivalent?  It seemed like a desperate move to make this technology seem more “green” than it is.

Once again, when dealing with an energy technology, we have to put this into the proper perspective. The technology is not an energy source (so it will not solve our energy problems, as Stahl asked of Colin Powell – for some reason). It is not a means of storing energy. It is simply a means of converting fuel into electricity – in other words it is a generator or power plant.

There are already power plants that burn natural gas to run their generators. So this is nothing new.

The real promise this technology offers is portability, which could allow for small businesses and even homes to generate their electricity locally. This is actually a direction that energy production may be headed in, and it makes a lot of sense.

Back when electricity was first coming into existence as a major utility, the approach was distributed power production, with small local power plants. However, the state of the art in the 19th and early 20th centuries was coal burning (of course, still used today) which produces a great deal of pollution. In order to reduce the pollution in residential areas and big cities, power production was moved to remote locations and the grid was built to distribute electricity.

This system has some inefficiencies and vulnerabilities. Anyone who has lost power is familiar with one – power lines can go down, stations can break down, and then there is no electricity until the problem is fixed, which can take hours to days. There is also energy lost in transmitting electricity through wires over long distance (primarily from resistance) – these losses are estimated at 7.2%. That’s not bad, but still – it’s 7.2%.

Another inefficiency, however, is the heat that is wasted in production. Essentially, we waste heat in producing electricity from a fuel source, then transmit that electricity to a remote location where it is often used to generate heat (primarily in the Winter, but year round for hot water). Local energy production could use waste heat to heat air or water. Newer power plants do recover some of the waste heat to generate more electricity, making the power plant more efficient, but still this is not as efficient as using the heat where it is ultimately needed.

So there are significant advantages to producing electricity on site, and even capturing any waste heat for local use. At present, the Bloom Box costs about $700,000 per unit, which can run a small business like a Starbucks. This is way too expensive for the home. Bloom Box hopes to get the cost of a basic unit below $3,000 over the next 5 years, which seems optimistic, but if they can do it then they might be viable. If such units can produce electricity more cheaply than buying electricity off the grid, then they may become popular.

As always, the details are what will determine the viability of the Bloom Box for the home: how much will they cost up front, what are the maintenance costs, how reliable and safe will they be, how long will it take for a unit to pay for itself with reduced electricity costs? Also – if they produce electricity more cheaply than the grid, can a consumer generate more than they need and sell it to the power company? Be the first on your block to have one of these generators, and make money providing electricity to all your neighbors.

Of course, power companies can buy the current $700k units and place them in neighborhoods to put electricity into the grid and sell to their customers. They could do this rather than build a huge centralized power plant (like the one that just exploded near my house in CT  – which was a natural gas power plant). This technology can also be useful for remote areas where it is difficult to get power lines.

The next question is – do we have the supply of natural gas to start using it widely for electricity generation? For those homes that already have a natural gas supply this would be an easier install. Those without would need to first be put on the gas grid.

Also – we need to consider energy loss in the gas grid, which is estimated to be about 1-2%. This is better than the electrical grid (at 7.2%).

Conclusion

This technology is interesting, and it already is being used by large companies for local electricity generation. But it is not a “green revolution” nor a game changer. It is not a new source of energy. It may become an important method to move electricity generation to a more distributed local system, rather than the current centralized and grid distribution system. We need to learn more nitty-gritty details of the technology, and further it needs to be tested more for reliability, safety, and efficiency. We’ll know in 5-10 years, probably, what real role, if any, it will play in our energy future.

One of the common questions (sometimes framed as a claim or justification) about unscientific and implausible treatments that frequently comes up is – if they don’t work, why are they so popular? The assumption (also made by some who oppose regulation of medical products) is that the consumer will perceive the medical value of products and adjust demand accordingly.

I and others who favor more scientific and effective regulation of health products and claims have argued that there are a host of factors distorting the market in favor of health products with appealing claims, even if they lack substance. I am not an economist, however. So it was heartening to read the very same arguments I have been making expressed from an economist’s point of view.

This paper by Werner Troesken, an economist from the University of Pittsburgh, explores the flourishing of the patent medicine industry from 1810 to 1939 in the US (when FDA regulation essentially shut it down).

Troesken explores many factors leading to this success, but what I found most interesting is that when you strip away all the complexity, Troesken shows how ineffective treatments will still flourish in the marketplace.

Inelastic demand with respect to product failures

The core concept of this paper is that the patent medicine industry demonstrated what Troesken calls “inelastic demand with respect to product failures” – in other words, people still wanted to buy patent medicines, even after their previous experience with such products resulted in failure.

He begins with a few reasonable premises. The first is that the patent medicines of the time did not work. We can say with historical hindsight that the products popular at the time were not effective in curing the diseases they were being used to treat – often serious illnesses that were common at the time, like tuberculosis, but which lacked any mainstream medical treatment. Most patent medicines were variations of the same product, in fact – a bit of alcohol, sugar, and some (essentially random) vegetable matter. Often the same products were marketed over and over again with different labels and claims. We can now say with a high degree of confidence that these elixirs did not cure tuberculosis, or seizures, typhoid, or any other ailment that was claimed. Troesken assumes a 100% failure rate for patent medicines.

Troesken also assumes that customers perceived this failure – they knew they were not cured of TB. For a bit more of background on this premise, however, Troesken explains that at the time the empirical model of assessing medicines was dominant. In other words, treatments were assessed purely on whether or not they worked, not on the plausibility of any putative mechanism. This is largely due to the fact that science had not yet progressed sufficiently to think productively about plausibility.

It is a very interesting side note that empiricism resulted in very slow and uneven progress in medicine. Scientific medicine began to improve dramatically, however, when it became increasingly founded upon basic science. I would add, however, that the technology of empiricism also improved – we got better at doing clinical experiments. I would argue that this debate continues today – that between pure empiricism (which functionally is represented by evidence-based medicine) and a more balanced mixture of basic and clinical science, which I and others advocate as science-based medicine.

In any case, Troesken argues that consumers were following an almost pure empirical approach to patent medicines. They did not know enough science, and not enough science was known, to assess the plausibility of the products, so they judged them entirely on whether or not they perceived a benefit.

This is Troesken’s basic model – medicines do not work, consumers judge them solely on whether or not they work, and consumers correctly perceive that they do not.

Interestingly (and I think this is the core insight of this paper) even with this basic model, Troesken argues that the patent medicine market would still flourish – as it in fact did. This is because (here is where the economics perspective comes in) the perceived value of a potential cure is extremely high, compared to the relatively low cost of experimenting with a new treatment. So consumers felt that they had little to lose and the world to gain, leading to repeated experimentation with, and even high demand for, patent medicines.

Troesken acknowledges that repeated failures would decrease the perceived value of patent medicines, but this perceived value would not go to zero – it would decrease asymptotically, and remain substantially high even after multiple failures.

In other words – the allure of a promised cure is so great, people are willing to risk the investment in the treatment even after repeated failures. We therefore cannot rely upon market forces to weed out ineffective treatments from the marketplace.

False positive and other factors

But of course – this is the most basic model. There are many other factors at work, and Troesken hits upon many of the ones I and my colleagues have discussed in the past, but not all of them. For example, he discusses how marketing was designed to produce “false positives” – this led to the testimonial, a fake patient giving a fake testimony about how the patent medicine worked for them. Consumers then incorporate the false positives of testimonials into their calculations, making the product demand even more resistant to personal failures.

Another potential source of false positives was actual active ingredients present in many patent medicines. Products often contained cathartics, purgatives, or even narcotics (and of course alcohol is an active ingredient). These substances may have caused dependence, and in fact some patent medicines may have been little more than a socially acceptable “back door” method of consuming illicit drugs. Or they may have produced physical effects that convinced consumers something biological was happening, such as removing toxins through purgatives.

What Troesken does not discuss much is the false positive of the placebo effect. This is because he is restricting his analysis to claims for cures of real diseases. In his basic model he ignores spontaneous remissions, but he acknowledges this is another source of false positives – sometimes people get better on their own. But the more serious the disease, the more rare this should be.

When we move into the arena of symptomatically treating chronic ailments that are not life-threatening, the placebo effects takes on a larger role. For example, many illnesses are self-limiting – they will get better with only tincture of time, and so any treatment will seem to work. Also, people with a fluctuating illness will tend to seek treatments when their symptoms are at their worst, and so regression to the mean will result in improvement after any treatment they take while symptoms are at their peak. There are also a host of other psychological factors leading people to perceive improvement in the absence of a real biological effect. (See here for more information on placebo effects.)

One factor I think Troesken gets a bit wrong is his conclusion that patent medicines thrived not only despite their lack of effectiveness, but because of it. He argues that if a patent medicine worked, and cured a client, that consumer would be removed from the pool of demand – they would no longer be seeking medicine. This is true (again within the limited model of patent medicines as cures for serious illnesses, rather than symptomatic treatments for chronic illnesses) but he ignores an important factor. If a person survives one illness, they will survive to get another – and when they do, they will likely return to what cured them the first time. Everyone is relentlessly aging, and with age comes increasing illness. Ironically, Troesken does accurately refer to this effect in a different context below.

The rise of science-based medicine

Troesken also argues that improvements in the knowledge base and effectiveness of scientific medicine did not, and would not be expected to, reduce the patent medicine market. The success of snake oil, in other words, should not be interpreted as a failure of or the absence of effective medicine. In fact, Troesken argues, the success of germ theory and increasingly scientific medicine meant that people were surviving the acute illnesses of their youth to become older adults – older adults with chronic ailments. Modern medicine, therefore, increased the pool of demand for patent medicines.

He also points out, and I would amplify, that increasing medical knowledge did not dampen the demand for implausible treatments. This is because the general public, while they may have increased scientific knowledge as scientific knowledge in general increased, would not rise to the point that they would reject patent medicines on the basis of scientific plausibility. They remained empiricists.

This matches our knowledge of belief in pseudoscience even outside the realm of medicine. Acceptance  of dubious science actually increases with education, until one gets to the post-graduate level of science education. It takes a very high level of scientific knowledge (and/or, I would argue, an understanding of the principles of scientific skepticism) to feel confident in rejecting a claim based upon plausibility alone. This is true even of health care professionals.

Patent Medicines Today

The classic era of patent medicines may have ended in 1939, but it has had a resurgence in the US since 1994, when DSHEA was passed. DSHEA essentially removed supplements and herbs out from under the yoke of FDA regulation, partly (at least on the right) based upon the claim that market forces were sufficient to regulate such products.

What is amazing to me is how the supplement industry of today is so similar to (and in some cases historically continuous with) the patent medicine industry of the 19th century. All of the same factors are in place – testimonials, cutting supplements with active ingredients (caffeine is now common, and of course some Viagra replacement herbal supplements were found to be cut with actual Viagra), the types of claims that are made for products (combining ancient wisdom with cutting edge science), and more.

I think Troesken makes a compelling argument for the inelasticity of demand for such products, which, in my opinion, undercuts some of the libertarian arguments made against regulation of supplements, and even (by some) pharmaceuticals. Some may still argue that the demands of personal liberty outweigh the goal of protecting the public from worthless products, or that regulations, despite good intentions, either do not work or have negative unintended consequences. I disagree (even while I am sympathetic to these arguments in principle, I disagree with how they are often applied in this context), but these arguments are not addressed by this paper.

What this paper convincingly argues is that we cannot expect market forces to result in better and more effective health products, or even to keep entirely worthless or even harmful health products from the marketplace.

This week on Science-Based Medicine I wrote an article about a new study looking at the onset of autism symptoms, showing that most children who will later be diagnosed with autism will show clear signs of autism at 12 months of age, but not 6 months. This is an interesting study that sheds light on the natural course of autism. I also discussed the implications of this study for the claim that autism is caused by vaccines.

Unfortunately, I made a statement that is simply wrong. I wrote:

Many children are diagnosed between the age of 2 and 3, during the height of the childhood vaccine schedule.

First, this was a vague statement – not quantitative, and was sloppily written, giving a different impression from the one I intended. I make these kinds of errors from time to time – that is one of the perils of daily blogging about technical topics, and posting blogs without editorial or peer-review. Most blog readers understand this, and typically I will simply clarify my prose or correct mistakes when they are pointed out.

However, since I often write about topics that interest dedicated ideologues who seek to sow anti-science and confusion, sometimes these errors open the door for the flame warriors. That is what happened in this case.

J.B. Handley, writing at Age of Autism, saw my error as a way to demonize me before his enthralled mobs – and he dives into his task with gusto – although without much care or attention to detail himself, as we will see. Handley also is clearly not interested in what the science actually says, only in grabbing a propaganda opportunity.

First, to clarify the facts, here is the childhood vaccine schedule from the CDC. As we can see, the majority of vaccines are given prior to the age of 2, many in fact at or before 12 months. While “height” is a vague term, it is certainly inaccurate in this case. Before I explore this issue further, however, let me address the other factual claim made in that statement.

I wrote that “many children are diagnosed between the ages of 2 and 3. About this statement Handley writes:

Firstly, the last time I checked, the average age of diagnosis for a child with autism was somewhere between 3-4 years of age, not 2-3.

In fact, the average age of diagnosis is 3.1 years (although to be fair other studies give the average at 3.6  – there is some regional variation).  This is “somewhere between 3-4 years of age” but Handley’s point is still incorrect. I did not write that the average age was between 2 and 3 but that many children are diagnosed between 2 and 3, which is certainly true if the average age at diagnosis is 3.1. In his exuberance, Handley simply got this wrong.

I don’t expect him to make a correction, however. The last time he attacked me, he make a rather amateurish mistake, confusing incidence and prevalence, and used his error as the basis of his criticism. He never admitted or commented in any way on his gross error.

But on to the substance of his latest attack. The point that I was trying to make, which I did in fact clarify later in my post, is that when parents attempt to date the onset of their child’s autism they typically will date the onset later than the true onset. As we now know, from multiple studies, true clinical onset (biological onset is likely earlier) is between 6 and 12 months. Parents may not notice this onset until much later, and formal diagnosis is later still. This diagnosis happens within the childhood vaccination schedule, so it is likely that parents will have some recent vaccine to point to when looking for factors that seem to correlate with the onset of autism.

That was my point – a point that I and many others have made previously. By pushing earlier the true clinical onset of autism this study adds to evidence against the involvement of later vaccines. It is true that many vaccine are given in the first year of life, and of course this study by itself does not let all vaccines off the hook – nor did I say that it does.

But I did discuss one vaccine in particular – the MMR vaccine. MMR has received more attention than any other vaccine as a potential cause of autism, thanks to the now-discredited work of Andrew Wakefield. The first dose of MMR is given at a minimum of 12 months of age, with the second dose being given between 4 and 6 years. Certainly this study is relevant to the claim that MMR is a significant cause of autism.

There is much evidence to support the conclusion that there is no correlation between MMR and autism. It should be obvious that this study is further evidence against a correlation. If most children with autism show signs by 12 months, then a vaccine which is not given prior to 12 months cannot be to blame. This was not obvious to Handley, however. He wrote:

In fact, between the ages of 2 and 3, children receive all of 2 vaccines, accounting for 5.5% of the vaccines they receive, while a full 70%, including MMR, come in their first 12 months of life, perfectly matching the time when this new study reported the beginning of a regression into autism!

Wrong, Handley. The MMR does not come “in their first 12 months of life.” At the very earliest it comes AT 12 months, which obviously cannot be responsible for symptoms that are present by 12 months. Maybe Handley was just sloppy in his choice of words (but it is odd that he went out of his way to mention MMR by name). Or maybe he is guilty of all the things of which he falsely accused me. This is certainly the same kind of error I made, although more specific. My error was inadvertent and I have readily admitted my mistake and am taking great pains to correct it. Let’s see how Handley responds when this error is pointed out to him.

The bottom line is that this study does in fact add to the body of evidence against an association between MMR and autism, because of the timing of the onset of autism.

Handley also takes exception to my point that parents may not accurately observe and remember when the onset of their child’s symptoms were. He makes one obvious point – that onset is not a moment in time but a process. I agree – but never implied otherwise. But even for diseases and disorders of insidious onset, there usually is a relatively brief period of time when the patient or family member really notices it – and that is when they date the onset.

I have the experience of actually seeing and diagnosing patients, reviewing their histories and comparing them to documented evidence in some cases. So I, like other experienced clinicians, understand this phenomenon well. For example, I see many patients with dementia, like Alzheimer’s disease, and they or their family will often date the onset of symptoms at a point in time some months prior to presentation, often anchored to a specific event (a phenomenon actually known as “anchoring”). But when I probe for specific details, it is apparent that there were signs of dementia for 1-2 years prior to the family’s dating of the onset. Or, I may have the benefit of a documented exam or history, clearly showing onset prior to the memory of those giving the history.

Handley seems naive to all of this, and rather he is content to grossly mischaracterize my point as calling parents “dumb,” which, of course, I never did. This is because Handley’s purpose, in my opinion, is not to meaningfully explore the evidence, but to demonize scientists and physicians with whom he disagrees. Read the comments to his blog and you will see that his attempts at demonizing me and others are quite successful in the echo chamber of his followers. He wrote:

Further, this notion by Novella that we parents are “telescoping” is simply the ridiculous introduction of a new and confusing term to try and explain away the chorus of tens of thousands of parents all screaming the same thing about what happened to their kids.

The authors of this study itself applied the concept of “telescoping” or dating autism onset as more recent that it really was. I simply used their term, which they in turn took from the literature. It is a well-described concept, not invented by me or this study’s authors – people remember events in the past as being more recent than they actually were. For Handley’s purposes, however, he wants to characterize a well-known and scientifically established psychological phenomenon as being equivalent to calling people stupid, or spinning reality.

I also showed that this phenomenon is absolutely relevant to the question of vaccines and autism, using the Cedillo case as an example. The Cedillos believed that their child acquired autism after receiving the MMR vaccine. However, home movies reviewed in the court case brought before the Autism Omnibus shows signs of autism in the first year – prior to the first MMR vaccine.

Further, Handley is now trying to argue that this new study supports a correlation between vaccines and autism. In fact, it does nothing of the sort. It does all but eliminate MMR, varicella, and Hep A as having any potential role in autism, as these vaccines all come after the onset of autism in most cases. Handley, if he were being intellectually honest, should admit this, but he doesn’t, and very dishonestly implies that MMR specifically is still a potential cause.

Average age of diagnosis of autism is about 3.1 years of age, and when that was the best information we had to go on the anti-vax movement argued that this showed a correlation with vaccines. Then clinical studies showed that the diagnosis could be reliably made between age 2-3 years of age, but that’s OK, that still correlates with vaccines. Now we know the age of clinical onset is between 6 and 12 months, and Handley is saying this still correlates with the vaccine schedule.

Since the HepB is given at birth, and other vaccines at 1-3 months, moving the diagnosis of autism up even further would still correlate with some vaccines. Since Handley is willing to blame any vaccines, regardless of type (live virus or otherwise) and ingredients (thimerosal or not) no age of onset would disprove his cherished vaccine hypothesis.

There is also nothing about the vaccine hypothesis that led anyone in the anti-vaccine camp to predict that the true age of onset of autism is earlier than it is being diagnosed, and certainly not to within 6-12 months of age. So Handley is just retrofitting – declaring whatever evidence there is as supporting his position.

Finally, Handley pulls the “pharma shill” gambit on me as part of his smear campaign. He trots out an accusation he has made before, portraying my association with the ACSH as being sinister. As I have already explained, my association with the ACSH is limited to me agreeing to advise them on areas of my expertise. That’s it. I have, in fact, performed zero work for them. I have had no contact with them, other than them sending me their public material, and I have never received any kind of remuneration from ACSH. I have corrected Handley on this before, so I know that he knows what he is writing is wrong, and he has failed to correct his errors.

Further my associations with the pharmaceutical industry are minimal – a couple lectures and consultations for nominal fees years ago (and nothing ever to do with vaccines). I have never received a dime from any company to express an opinion on a scientific topic, or write a particular blog or article. I suppose that Handley believes my many hours of work producing podcasts and blogs and promoting science and skepticism is all an elaborate smokescreen for shilling for industry, all without receiving a dime for my efforts, which makes me the worst shill ever.

Actually, I don’t suppose that at all. Rather I think that Handley knows that what he is writing is pure BS, especially since I have called him on it before, and openly challenged him to produce a shred of evidence to support his false accusations. But Handley knows the narrative of the anti-vaccination movement – everyone who denies that vaccines are evil are themselves evil shills for even more evil industry.

Conclusion

In the end, all that matters is the science, which clearly shows that there is no association between vaccines and autism. This one study has minimal implications for an alleged connection, except that it clears the most often implicated vaccine – MMR. It also supports other evidence that the onset of autism is earlier than many parents observe and much earlier than formal diagnosis, which calls into question any casual observations about the timing of onset to any potential triggers.

In my first article on this topic I was sloppy in that one sentence about the vaccine schedule – an error I have now corrected. But that error did not affect the relevant points I made in the rest of the article, which I have also amplified here.

J.B. Handley thinks he has scored some points for his side by jumping on my error, but he has only shown himself, once again, to be a propagandist with no regard for science, accuracy, or even common decency.

In a pattern that is becoming all too familiar – naturopath Christopher Maloney has forced the shutdown of a blog that was critical of his medical advice. Student Michael Hawkins wrote in the Kennebec Journal:

Naturopathic medicine is pure bull.

Let’s not beat around the bush on this one. Those who practice naturopathy are quacks. They may be sincere quacks, but sincerity does not translate to evidence — or your health.

He expressed similar views on his blog, which was hosted by Wordpress. Maloney allegedly responded with the British Chiropractic Association (BCA) maneuver, not by defending his claims, but by complaining about the content of Hawkins’ blog to Wordpress, who responded by demanding that Hawkins censor his criticism. Hawkins apparently made changes, but not sufficient to please the Wordpress censors, and so they shut him down. (Note – Maloney claims he never complained to Wordpress and had nothing to do with the shutdown.)

By now you should know what happens next – fellow science and reality-based bloggers (most notably PZ Myers) got wind of the story and decided to amplify Hawkins’ criticism by many orders of magnitude.

What sparked Hawkins’ criticism of Maloney was this article, also in the Kennebec Journal, that was nothing but a thinly-veiled advertisement for Maloney’s practice, in which Maloney wrote:

It will have no effect on deadly complications in any population group (Cochrane). No study of flu vaccinations has shown any benefit for children under 2, and every year half of those killed from vaccine side effects are under 2 years old. (Cochrane and CDC data for the last 10 years). Those promoting vaccination should provide published research to inform patients.

Parents waiting for vaccinations can provide their children with black elderberry, which blocks the H1N1 virus. A single garlic capsule daily cuts in half the incidence and the severity of a flu episode for children.

Maloney pulls the typical CAM fast one here. First he disparages the efficacy of the flu vaccine, then scaremongers about side effects, without providing any actual numbers. I prefer this summary of flu vaccine efficacy by Mark Crislip. Mark acknowledges that this is a complex question without a simple yes/no answer. The flu vaccine is not a great vaccine, as vaccines go, but it does have efficacy, and clear benefit in excess of risk. Serious vaccine reactions are “very rare”, according to the same CDC sources that Maloney is apparently referring to. Life threatening adverse events occur on the order of 1/100,000 to 1/1 million injections. Meanwhile, 30,000 or so people die each year from the flu.

After Maloney cherry picks information to scaremonger about the flu vaccine, he then recommends elderberry and garlic. Ironically, he exhorts mainstream practitioners offering the flu vaccine to provide published research – then he recommends two treatments without reference to published research. Let’s take a look at the published research, shall we.

First – elderberry contains chemicals (specifically flavonoids) that have pharmacological activity. So there is some plausibility for biological activity. And in fact there are in vitro studies showing that flavonoids from elderberry extract have anti-H1N1 flu virus activity. But, as I discussed just yesterday, it is not appropriate to extrapolate from such basic science data to net clinical effects. If these flavonoids turn out to be useful, it will be because they are isolated, purified, and then studied in specific doses – in other words, just like any other drug. Perhaps this will lead to the development of the next Tamiflu. Meanwhile, I would recommend using Tamiflu – which as already been purified and studied clinically.

There is also one clinical study showing some effect, but this is a small and preliminary study. Most such preliminary studies will turn out to be wrong, when larger better studies are done. We have been through this with just about every popular herbal remedy, from echinacea to gingko biloba – early studies showing promise followed by large definitive studies that are dead negative.

So, in essence, black elderberry shows promise as an eventual source for an anti-viral treatment, but it is still preliminary and therefore unreliable. So Maloney is recommending a treatment with unreliable evidence (one small study) in favor of one with far more evidence (literally hundreds of studies and thousands of published papers).

My PubMed search on “garlic” and “flu” or “influenza” gave 7 results total. There was only one paper that looked like a clinical study – a Japanese paper from 1973 (unfortunately no abstract is available online).

Maloney’s website has this to say:

Volunteers taking garlic capsules had half as many flus, and the flus were half as long. Adv Ther. 2001 Jul-Aug;18(4):189-93

But the reference cited was for the common cold – NOT the flu. Apparently, naturopathic training did not prepare Maloney to distinguish the cold from influenza.

Further, Maloney is massively cherry picking (even from evidence not relevant to the question). A Cochrane review of garlic for the common cold concluded:

There is insufficient clinical trial evidence regarding the effects of garlic in preventing or treating the common cold. A single trial suggested that garlic may prevent occurrences of the common cold, but more studies are needed to validate this finding. Claims of effectiveness appear to rely largely on poor quality evidence.

Once again we see the reliance on cherry picked weak evidence that may not even be relevant to the clinical question, while disparaging science-based treatments. This is the standard of science within naturopathy.

Conclusion

Hawkins was correct to criticize Maloney and his claims. Maloney, rather than defend his views, decided to silence criticism, and Wordpress should be ashamed for caving to such obvious censorship of important public debate.

But in our brave new world at least there are science-based outlets that will not let criticism of pseudoscience be silenced.

Thanks to PZ for bringing this to wider attention.

Addendum:

This story developed rather quickly yesterday. We now know that it is Andreas Mortiz who is threatening lawsuits against Hawkins, and now PZ Myers as well, as an intimdation tactic.

PZ has the update here: http://scienceblogs.com/pharyngula/2010/02/andreas_moritz_is_a_cancer_qua.php