Category Archives: Medicine

Medicine, Science

The great vaccination scare

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Most of you will have heard of the MMR vaccine controversy. A man, Dr. Wakefield, suggested that the MMR vaccination increased the likelihood of autism in infants and children. People stopped vaccinating their kids, which resulted in a few thousand cases and a few deaths. All of them could have been avoided, had it not been for Dr. Wakefield.

As we know, people don’t learn from their mistakes, the deep-rooted fear still possesses them. In a previous blog entry, I talked about my homeopath/M.D. aunt, among other things. She’s a lot of things I could make fun of, but one of the things that makes me sad is that she also opposes vaccines. She went to Kenya without a single vaccination, even though yellow fever is a deadly disease. Her whole family is the same, they all oppose vaccinations.
Recently, I talked to a friend of mine. She’s also against vaccinations, because they can “harm your immune system”.

Let’s look at anti-vaccers claims:

Vaccines are not effective, vaccines are not safe, vaccines are not moral or vaccines are against my religion.

We can dismiss the last two claims out of hand. If you don’t want to use them due to your religion then your religion is pretty fucked up.
I also reject the case for personal liberty. If your idiocy is putting other people at risk, you have no say. Period. Your rights should be stripped away to protect the rest of the population.

So we’re left with two questions:

1) Are vaccines effective?

2) Are vaccines safe?

The efficacy-question is easily answered: Vaccines are among the few things to come out of the pharma-industry that are so very obviously effective that we shouldn’t even have to think about this.

Forbes recently posted a short article on the topic. The following info-graphic was compiled from a recent article, linked in the Forbes-post.

Vaccines Info-graphic

Smallpox was once one of the most prolific killers, with an estimated 300-500 million killed just from Smallpox alone. And now, it’s virtually eradicated.

Thanks to vaccines? I think the above is ample evidence to that extent, but there’s more. The following graphic (Wikipedia) was compiled for the prevalence of rubella, but it could equally have been compiled for any other vaccine. It always follows the same path: A vaccine is introduced and given, the prevalence of the disease goes down.

Prevalence of rubella

 

So on to the second argument: Safety.

When I was a baby, I was immunized against MMR. The batch I received was tainted, I fell ill. I could have died, but was given medication and survived. But even in the best of circumstances, people can have adverse reactions to the immunizations.

Here’s the deal though: These reactions are incredibly unlikely to happen.
A paper from a  few years ago discussed this and came up with the following conclusion: “[T]he expressed doubts about the safety of vaccines are unjustified.”
That’s it really. Vaccines are an effective and safe way to counter several potentially deadly diseases. To eradicate these diseases, we all need to take the vaccines. If you don’t immunize yourself, you not only put yourself at risk but also the rest of the population, by allowing the disease to survive.

I don’t think any argument can be made that vaccinations are dangerous or ineffective. If you think there is, please, I need a laugh right about now.

Education, Medicine

Evidence-based medicine: Introduction Part 2

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In my first post on medicine I talked about the various dangers that can arise from medicine that’s neither effective nor particularly harmful. In my second post, I talked about one particular alternative medicine, PSE, showed that it’s not based on any evidence whatsoever and most likely does not work, though that can’t be confirmed because in it’s 15-year runtime it has yet to be properly and fairly tested. That’s fairly common in alternative medicine.

In this post, I want to tackle an argument you can often hear from advocates of alternative medicine: “Why should I want evidence when all the “evidence-based” medicine isn’t based on any actual evidence?” I’ll also give an introduction into evidence-based medicine, albeit a very brief one.

For the purpose of this post, I’ll recommend two excellent books:

Goldacre, B. (2012) Bad Pharma – How drug companies mislead doctors and harm patients

Evans, I., Thornton, H., Chalmers, I. & Glasziou, P. (2006) Testing Treatments – Better research for better healthcare

About 90% of my examples come from these two books, mainly because they give nearly all the relevant sources. (Meta studies and so on)

As Evans et al. document: (P.13-14) As a parent, the most horrible thing that can happen to you is your child dying. Naturally, parents will immediately do what a doctor tells them if it’s said to reduce infant suffering and death. In 1946, Dr. Benjamin Spock‘s book “Baby and child care” suggested babies sleep on their backs. In 1956, he revised that statement, saying:

There are two disadvantages to a baby’s sleeping on his back. If he vomits he’s more likely to choke on the vomitus. Also he tends to keep his head turned towards the same side… this may flatten the side of the head… I think it is preferable to accustom a baby to sleeping on his stomach from the start.

That sounds like incredibly sound advice, which is why many parents (millions?) opted to do so. However, there was one serious flaw: This practice, never evaluated, led to an estimated 50,000 deaths. A first study suggesting harm was published mid 1960’s, a second in the early seventies, two further ones in the mid 80’s. It was only properly acted on in the mid 90’s. (In some cases until 2002!)

Now one might argue that this is a case of “evidence-based medicine” gone wrong. I disagree, it’s precisely the opposite. Here, no evidence or very shoddy evidence was provided, which eventually led to tens of thousands of deaths. Had the evidence been appraised correctly right away, many if not most of these deaths might have been avoided.

There are dozens of examples like this in the two books, so I won’t go through them. The authors have gone to great pains to document these cases and I recommend you read about them yourselves. I just want to bring this back to the point I was trying to make: Evidence-based medicine can only function if we look at the evidence carefully and without bias, and if we then act on the evidence as swiftly as possible.

This system is by no means perfect, because humans will always find a way to either intentionally interfere with the process (for political or monetary reasons) or to be so stupid as to fuck up. However, it’s better to have a system that’s based on evidence we can theoretically gather (evidence-based medicine) than basing it on a system that involves nothing more than guesswork. (alternative medicine)

At this point, I should probably point out how incredibly fragile this review process is. Ben Goldacre documents: (P. 69)

Imagine you’re conducting a study on a particular drug. Let’s call it pregabalin, a drug to help diabetics handle pain when their nerves have been affected by the disease. You gather test subjects, you double-blind the study, you do everything you’re supposed to. But some subjects drop out of the study, due to various reasons. It might be that they still feel pain and don’t want to continue or the side effects might be too severe. Whatever the reason, you’re now faced with a problem. You’ve got half a dataset for the drop-out patient. How can you incorporate the results in the study?

The researcher, let’s call him Pfizer, does a clever thing: He uses the “last observation carried forward”-method. That’s a fancy sounding name for “I’ll put down the last result I got into every column. Basically, the patient had pain levels of 10, 9, 8, 7, 6, 5, 5, 6, 5, and then dropped out. So Pfizer fills in the last six data-points with all 5’s. Before the study, you will notice, the patient had pain levels of 10.

The research then gets published and your drug looks quite good indeed. But wait! what’s that? Some researchers disagree with your method? But why? Well, the reasoning is this: The patient dropped out, so their pain level is back to 10. Obviously, the side effects were worse than the pain and they stopped using the drug. So we have to put all 10’s for the last six data-points instead of all 5’s. That’s called the “baseline observation carried forward”-method.

The difference between the two methods is staggering: With the LOCF the drug gets overestimated by nearly 25%!

That, you will agree, is quite a lot. Once again it shows: Medicine must be based on the best possible evidence, not on guesswork and shoddy methods.

I’ll leave you with a few points:

  • Biased testing will leave you with incorrect data, thus putting patients at risk.
  • All medicine should be tested and carefully evaluated. Failing to do so puts patients at risk and should be persecuted.
  • Trusting doctors blindly is not always a good choice. Ideally, your doctor should be able to show you what research (s)he’s basing his/her decision on.
  • Basing therapies on theories instead of real-world outcomes is again putting patients at risk.
  • As suggested in my first post, using treatments that are neither directly harmful nor beneficial is also not recommended.
  • Established treatments are not necessarily beneficial: Check and re-check. I explained that partially in my second post.
  • Tests should be as fair as possible, that is to say: Randomised (double-blinded) Controlled Tests (RCT’s), comparing like with like, meta-studies, etc. This requires that potential researchers and future doctors be trained in the best available methods.

I’ll leave it at that and once again recommend the two above mentioned books. Remember, all science needs evidence and we need laws to ensure the best standards.  We need institutions like the Cochrane Collaboration to appraise the available evidence without interference from commercially or politically driven institutions. Read “Bad Pharma”, it’ll really shock you.

Medicine, Research, Science

Evidence-based medicine: Introduction Part 1

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In my last post, “What’s the harm?”, I talked about the problems of taking medicine (or treatments!) that’s neither good nor bad for you. I also talked about “evidence-based medicine”, but didn’t really delve into that topic. I won’t do that in this post, either!

So what, you may well ask, do I want to talk about now? I want to give you a look into what a few doctors do and why their approach is deeply flawed. I’ll give one specific and not-well-known example of alternative medicine as well as some obstacles I found when investigating its efficacy.

In short, I’ll talk about why medicine needs evidence and why practitioners of alternative medicine might be reluctant to look for evidence. I apologise if the post is fairly long, but I need to flesh out my example to make sure you understand the practices behind it.

 

First, let me try to explain PsychoSomatic Energetics (PSE).

Watch this video. Read this page. (If you speak German, read this book. Or don’t, it costs money… Twenty pages are also available here.)

Done? Now what do you know about PSE? Not very much, I’d think. You know it has something to do with “energy blocks” and with measuring the “subtle energy field”. But how does it work?

Here’s where I come in. I’ve read the book and I’ve talked not only to people who’ve taken a seminar in PSE, meaning they’re qualified to test with it, but I’ve also E-Mailed one of the inventors of PSE, the ex-Wife of the guy in the video. What I will now lay out will sound confusing, mad even. If you don’t trust me, read the book and cross-check what I’ve said. If anything I’ve said sounds exaggerated or false, feel free to criticize me in the comments.

PSE is based on Freud’s psychoanalysis, basically issues from the past are said to influence your current health. In Freud’s case, that meant mental health, in PSE language mental health influences physical health. Up until now, the theory’s sound. Of course depressions and other mental problems can affect the body, but the effects can be hard to spot and even harder to treat.  That’s why psychotherapy is such a difficult field, why so many therapists have to take long vacations and why they are given the harshest, yet most self-preserving advice.*

Here, then, is PSE’s amazing promise: Not only can we find out what is wrong, and how much is wrong, but we’ll even be able to cure them in a relatively short time using homeopathic remedies. Now we haven’t yet looked into homeopathy, so we’ll assume for now that the remedies are 100% effective. That’s how generous I have to be just to take PSE seriously. So what should strike us about the above is this: It claims to cure all energy-related problems. Any remedy that claims to cure everything of anything can be almost immediately dismissed.

Now I’ve failed to tell you two things:
1) What does PSE supposedly treat? “Energy problems” is not very specific a term in this context. I’d refer you to Dr. Banis’ book, but that’s not very helpful: “Most illnesses are caused by blockades of the soul, which can’t be tested nor treated early enough. That’s what we try to counter with PSE.” If you found that illuminating: Congratulations, you’re smarter than I am.
I have talked to some people though, and their answer is the same: “Almost everything can be treated with PSE, if it’s found early enough”. I’ll be generous and say “Non-serious mental problems (slight depressions, slumps, feeling worn-out, etc.) and small boo-boos (coughs, “feeling unwell”, etc.) can be treated”.

2) What is energy and how does it relate to PSE?
Remember that PSE is bound to eastern traditional medicine. In that tradition, the body has “energy” and that energy is located in one of the seven “chakra-points”. That energy is generally an astral “energy”, a sort of “I’m full of energy”-thing, but recent attempts (Deepak Chopra et al.) have tried to make this “energy” a real energy, a physical force.
If you read the PSE-book I’ve referenced above, you can find at least three definitions of energy:
a) The above described astral energy
b) Magnetism, in this case the slight magnetic field around the body.
c) The energy we know from physics known as “force” and the energy we know from electricity known as “electric charge”.

According to PSE, we can measure the energy at every chakra-point on a scale from 1-100, with every one of those points further being divided into four “energies” known as “vital”, “emotional”, “mental” and “causal”. We don’t  need to understand them, we just need to know that according to PSE, if any one of those energies suffers (note: that’s 28 different measurements!) then we won’t have enough energy, which can either result in us feeling depleted (think of it as forgetting to turn off a light at home, it drains your money) or in us becoming sick (a light bulb pops due to it being overused). I won’t go to tell you that it’s then compared to the four “juices” of the body, also known as the “four temperaments“. That would just be mean and discredit the whole thing immediately.

In any case, back to PSE. Now that we’ve understood what is to be tested, we can see how it is tested. The process is relatively simple:

Take a machine, in this case the Reba® special test device and hook the patient up to it. You do that by placing the machine on a flat surface, lying the patient down next to them and attach a wristband to one of their wrists.
Next, you take an vial of the homeopathic remedy you want to test (one vial corresponds to one of the 28 levels I described above) and place it into the receptor of the machine. Note that at no point does the actual remedy get into contact with the device.
Having done that, you switch on the machine and test for the first of five levels. (100/5=20, so you test at 20, then 40, then 60, etc.) To do that, you (being the doctor) take the arms of your patients and lightly pull on them. (Arms outstretched behind/above your head) If one arm is longer than the other one (supposedly called “kinesiological arm-length reflex”), you know that energy is lacking.

Practical example: If you test vial one and your patients arms are the same length at 20, but one is shorter at 40, then you write down “20”, because that’s the “available energy level”. If they’re the same length at 20 and 40, but different at 60, you write down 40. And so on.

And that’s it, basically. You repeat that 28 times and write down the results. If they’ve got energy level 100 everywhere save for vial 28 (associated with “wrong thinking”), you give them remedy 28 to “boost their energy level” at that point. After six to twelve months, the patients come back and if they tell you that they feel better, then everything’s fine. If they don’t, you re-test them and give them more remedies.

Now obviously, there’s so much wrong with that, I won’t be able to go into all. A quick overview:

  • What is energy and why do they use so many different, conflicting definitions?
  • How can PSE supposedly treat “everything”?
  • How can we test if “chakra-points” really exist?
  • Why are they using outdated concepts like the “four-temperament” theory?
  • How does the test device work?
  • Is the arm-reflex reliable? (Hint: NO!)
  • Isn’t the whole thing a bit subjective?

But most importantly of all, I want you to focus on one very specific problem: Where’s the evidence that it works? Anybody can say that it works (more on that much later), but how can I prove that it does?

Here’s where PSE encounters some very serious problems. There are four!!! relevant studies to this, with a total sample size of about 2000-2500. That’s not a bad sample size, it should be enough to see if PSE works or not. Below are the four studies:

Schmetterlingsstudie – Butterflystudy

Banis R, Banis U: Psychosomatische Energetik – Ergebnisse einer Praxisstudie. Schweiz Zschr Ganzheitsmed 2004;16:173–178.
Holschuh-Lorang B: Psychosomatische Energetik in der Allgemeinmedizin – Ergebnisse einer Praxisstudie. Schweiz. Zschr. GanzheitsMedizin 2004;18,368–371.
Banis R: Multizentrische Praxisstudie zur Psychosomatischen Energetik. Schweiz Z Ganzheitsmed 2010;22:269–272.

If you look at them, they all document a large percentage of “good” and “very good” results. But didn’t I just tell you PSE had serious problems when it comes to evidence?

Yes, because the above is not evidence of anything. It’s worthless trash, not worth the bits it’s written in.
That may sound harsh, but I’ll explain myself and I hope you’ll share my view.
Take note, because this is what the whole post has been building up to!

Eye-witness testimony is the lowest form of evidence in science, especially so in medicine. You can get better without the medicine or treatment doing anything (placebo effect), you can think you’re getting better even though the evidence shows no benefit and you can think the drug as a whole is beneficial (just not in you) even when it’s actually actively killing people. In his excellent book Bad Pharma, Ben Goldacre documents (pages 140-143) the effects of a drug called Iressa on the general population. Basically, Iressa showed no real-world improvements for patients, yet they gave positive testimonies nonetheless.
So at the very least, we can expect PSE to look slightly beneficial just due to this misinformation or misunderstanding or whatever you would like to call it. We will also expect it to look more beneficial because of the placebo effect and, because often people go to get treated with nothing more than “feeling bad” or “anxiety”, even better because people care for them and talk to them.

None of that would matter if PSE were ever tested fairly, that is to say using real, measurable effects. Since none exist (bar the subjective “I feel well” from patients), we would at the very least expect PSE to be tested against a placebo. After all, we know how potent the placebo effect can be. No, none of that. After over 15 years of PSE having been practised, NOT A SINGLE study has been conducted comparing PSE to a placebo. I even went as far as suggesting a cooperative effort between Dr. Banis and myself, but that failed due to a number of factors. (She was interested and would even cooperate with me, but no suitable venue nor funding was found.)

This is what this post has been about: More than fifteen years of practising PSE have passed and we don’t even know the most basic thing about it: Does it work? (I’d say no, but then you shouldn’t take my word for it.)

So I asked a practitioner (or at least advocate) of PSE about the lack of evidence for PSE, not to mention the various pieces of evidence against PSE. What does she make of that?
Her response: “I don’t care about evidence, I have seen it work with my own eyes. And I probably wouldn’t change my mind if I saw studies to the contrary.”

This staggering lack of curiosity about the evidence is baffling. Why don’t you want to know if it works? Isn’t evidence something to actively seek out? And even if you don’t want to conduct the studies yourself, wouldn’t you at least like to know?
Interestingly, I was then chastised by nearly everybody at the table for daring to challenge a doctor and for being a “damn skeptic”.

So as of today, the evidence is still not in on PSE, but it most definitely is in on homeopathy and since that doesn’t work we can safely assume that PSE doesn’t work either. If new evidence comes along, I’ll review my view and make a second post on this issue.

For now though, I hope you’ve taken one thing away from this: Medicine needs evidence, otherwise we don’t know if something works or not. I’ll give specific examples for that in the next post, this one here was mainly to give one example of practitioners or advocates of alternative medicine being reluctant to seek out evidence against which to measure their medicine or treatment.

Beware of alternative medicine.
*In a lecture, future therapists were told the following: “Some day in the future, a person will walk through your door. This person will be extremely friendly and will immediately open up to you. They’ll tell you that you’re the only person who’s ever understood them and that all previous doctors just couldn’t find the answer but that they just know that you’ll be better. If that ever happens, THROW THEM OUT! They’re lunatics and you can’t help them”. -unsourced

Edited by Dean, 06/03/2013
Reason for edit: Spelling correction [1].