Download Lectures on Biostatistics (1971). Corrected and searchable version of Google books edition
Download review of Lectures on Biostatistics (THES, 1973).
The Atlantic is an American magazine founded (as The Atlantic Monthly) in Boston, Massachusetts, in 1857. It is a literary and cultural magazine with a very distinguished history. Its contributors include Mark Twain and Martin Luther King. So it was pretty exciting to be asked to write something for it, even with a 12 hour deadline.
Sadly though, in recent years, the coverage of science in The Atlantic has been less than good The inimitable David Gorski has explained the problem in Blatant pro-alternative medicine propaganda in The Atlantic. The immediate cause of the kerfuffle was the publication of an article, The Triumph of New-Age Medicine. It was written by a journalist, David Freedman. It is very long and really not very good. It has been deconstructed also by Steven Novella.
Freedman’s article is very long, but it boils down to saying I know it doesn’t work but isn’t it nice. The article was followed up with Fix or Fraud: a ‘debate’., The debate is rather disappointing. It suffers from the problem, not unknown at the BBC, of thinking that ‘balance’ means giving equal time to people who think the earth is flat as it gives to people who think it is a oblate spheroid. The debate consists of 800 word contributions from seven people, six of whom are flat earthers, and one of which is very good. Try Steven Salzberg, A ‘triumph’ of hype over reality for some real sense. One of the flat earthers is director of a National Institutes of Health institute, NCCAM.
And this is a magazine that published not only Mark Twain, but Abraham Flexner, the man who, in 1910, put US medical education on a firm scientific footing, You can read Flexner in their archive. Mark Twain said
[A reply to letters recommending remedies]:
Dear Sir (or Madam):–I try every remedy sent to me. I am now on No. 67. Yours is 2,653. I am looking forward to its beneficial results. – quoted in My Father Mark Twain, by Clara Clemens
"allopathy is good for the sane and homeopathy for the insane"
So here is the piece, produced rather rapidly, for the debate. This is the original unedited version, slightly longer than appears in The Atlantic.
The title for The Atlantic piece, America, Land of the Health Hucksters, was theirs not mine. There is no shortage of health hucksters in the UK. but at least they mostly haven’t become as embedded within univerities and hospitals as much as in the USA.
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David Freeman’s article, “The Triumph of New Age Medicine” starts by admitting that most alternative treatments don’t work, and ends by recommending them. He takes a lot more words to say it, but that seems a fair synopsis. It is the sort of thing you might expect in a cheap supermarket magazine, not in Atlantic. The article is a prime example of rather effective sales technique, much beloved of used car salesmen and health hucksters. It’s called bait and switch. It’s true that medicine can’t cure everything. That’s hardly surprising given that serious research has been going on for barely 100 years, and it turns out that the humans are quite complicated. But the answer to the limitations of medicine is not to invent fairy stories, which is what the alternative medicine industry does. There is no sensible option but to keep the research going and to test its results honestly. It’s sad but true that Big Pharma has at times corrupted medicine, by concealing negative results. But that corruption has been revealed by real scientists, not by health hucksters. In the end, science is self-correcting and the truth emerges. Health hucksters, on the other hand, seem incapable of giving up their beliefs whatever the evidence says. The idea of patient-centered care is fashionable and care is great, if you can’t cure. But there’s a whole spectrum in the wellbeing industry, from serious attempts to make people happier, to the downright nuts. The problem is that caring for patients make a very good bait, and the switch to woo tends to follow not far behind. I write from the perspective of someone who lives in a country that achieves health care for all its citizens at half the cost of the US system, and gets better outcomes in life expectancy and infant mortality. The view from outside is that US medicine rather resembles US religion. It has been taken over by fundamentalists who become very rich by persuading a gullible public to believe things that aren’t true. One of Freedman’s problems is, I think, that he vastly overestimates the power of the placebo effect. It exists, for sure, but in most cases, it seems to be small, erratic and transient. Acupuncture is a good example. It’s quite clear now that real acupuncture and sham acupuncture are indistinguishable, so it’s also quite clear that the ‘principles’ on which it’s based are simply hokum. If you do a non-blind comparison of acupuncture with no acupuncture, there is in some trials (not all) a small advantage for the acupuncture group. But it is too small to be of much benefit to the patient. By far the more important reason why ineffective voodoo like acupuncture appears to work is the “get better anyway” effect (known technically as regression to the mean). You take the needles or pills when you are at your worst, the next day you feel better. It’s natural to attribute the fact that you feel better to the needles or pills, when all you are seeing is natural fluctuations in the condition. It’s like Echinacea will cure your cold in only seven days when otherwise it would have taken a week. If the article itself was naïve and uncritical, the follow up was worse. It is rather surprising to me that a magazine like Atlantic should think it worth printing an advertorial for Andrew Weil’s business. Surely, though, Josephine Briggs, as director of an NIH institute is more serious? Sadly, no. Her piece is a masterpiece of clutching at straws. The fact is that her institute has spent over $ 2 billion of US taxpayers’ money and, for all that money it has produced not a single useful treatment. All that NCCAM has done is to show that several things do not work, something we pretty much knew already. If I were a US taxpayer, I’d be somewhat displeased by that. It should be shut down now. At first sight Dean Ornish sounds more respectable. He bases his arguments on diet and life style changes, which aren’t alternative at all. He’s done some research too. The problem is that it’s mostly preliminary and inconclusive research, on the basis of which he vastly exaggerates the strength of the evidence for what can be achieved by diet alone. It’s classical bait and switch again. The respectable, if ill-founded, arguments get you the foot in the door, and the woo follows later. This is all very sad for a country that realized quite early that the interests of patients were best served by using treatments that had been shown to work. The Flexner report of 1910 led the world in the rational education of physicians. But now even places like Yale and Harvard peddle snake oil to their students through their "integrative medicine" departments. It’s hard to see why the USA is in the vanguard of substituting wishful thinking for common sense and reason. The main reason, I’d guess, is money. Through NCCAM and the Bravewell Collaborative, large amounts of money have been thrown to the winds and businesses like Yale and Harvard have been quick to abandon their principles and grab the money. Another reason for the popularity of alternative medicine in parts of academia is that it’s a great deal easier to do ‘science’ when you are allowed to make up the answers. The "integrative medicine" symposium held at Yale in 2008 boggled the mind. Dr David Katz listed a lot of things he’d tried and which failed to work, His conclusion was not that they should be abandoned, but that we needed a "more fluid concept of evidence". You can see it on YouTube, Senator Tom Harkin’s promotion of NCCAM has done for the U.S. reputation in medicine what Dick Cheney did for the U.S. reputation in torture. It is hard to look at the USA from outside without thinking of the decline and fall of the Roman Empire. One had hoped that era was over with the election of Obama, but the hucksters won’t give up without a fight. They are making too much money to do that. |
Follow-up
The comments that appeared in The Atlantic on this piece were mostly less than enlightening -not quite what one expected of an intellectual magazine. Nevertheless I tried to answer all but the plain abusive comments.
More interesting, though, was an editorial by Jennie Rothenberg Gritz, the Atlantic Senior Editor who asked me to contribute. The Man Who Invented Medical School. It picked up on my mention of Abraham Flexner, and his famous 1910 report [download from Carnegie Foundation] which first put US medial education on a form rational footing. based on science. Now, 100 years later that’s being unpicked both in the USA and here. ms Gritz seemed to think that Flexner would have approved of Dean Ornish. In a response I begged to differ. I’m pretty sure that Felxner would have been furious of he could have seen the reecent march of quackademia, particularly, but not exclusively, in the USA. It is exactly the sort of thing his report set out, successfully, to abolish. He wrote, for example,
“the practitioner is subjected, year in, year out, to the steady bombardment of the unscrupulous manufacturer, persuasive to the uncritical, on the principle that “what I tell you three times is true.” Against bad example and persistent asseveration, only precise scientific concepts and a critical
appreciation of the nature and limits of actual demonstration can protect the young physician.” (Flexner report, 1910, pp 64-65)
It is this very “appreciation of the nature and limits of actual demonstration” that is now being abandoned by the alternative medicine industry. despite the fact that real medicine was in its infancy at the time he w as writing, he was very perceptive about the problems. Perhaps Freedman should read the report.
David Katz seems to have spotted my piece in The Atlantic, and has responded at great length in the Huffington Post (quite appropriate, given the consistent support of HuffPo for nonsense medicine). HuffPo allows only short comments with no links so I’ll reply to him here.
I fear that Dr Katz doth protest a great deal too much. He seems to object to a comment that I made about him in The Atlantic.
“… [He] listed a lot of things he’d tried and which failed to work. His conclusion was not that they should be abandoned, but that we needed a ‘a more fluid concept of evidence.'”
You don’t have to take my word for it. You can take it from the words of Dr Katz.
"What do we do when the evidence we have learned, or if we care to be more provocative, with which we have been indoctrinated, does now fully meet the needs of our patients"
It seems odd to me to regard teaching about how you distinguish what;s true and what isn’t as "indoctrination", though I can understand that knowledge of that subject could well diminish the income of alternative practitioners. You went on to say
"Some years ago the CDC funded us with a million dollars to do what they referred to initially as a systematic review of the evidence base for complementary and alternative medicine, Anybody who’s ever been involved in systematic reviews knows that’s a very silly thing. . . . Well we knew it was silly but a million dollars sounded real [mumbled] took the money and then we figurered we’d figure out what to do with it [smiles broadly]. That’s what we did ". . .
I do hope you told the CDC that you did not spend the million dollars for the sensible purpose for which it was awarded.
This infusion of calcium, magnesium and D vitamins and vitamin C ameliorates the symptoms of fibromyalgia. . . . We did typical placebo controlled randomized double-blind trial for several months . . . we saw an improvement in both our treatment and placebo groups . . .
You then describe how you tested yoga for asthma and homeopathy for attention deficit hyperactivity disorder, Neither of them worked either. Your reaction to this string of failures was just to say “we need a more fluid concept of evidence”
After telling an anecdote about one patient who got better after taking homeopathic treatment you said £I don’t care to get into a discussion of how, or even whether, homeopathy works”. Why not? It seems it doesn’t matter much to you whether the things you sell to patients work or not.
You then went on to describe quite accurately that anti-oxidants don’t work and neither do multivitamin supplements for prevention of cardiovascular problems, And once again you fail to accept the evidence, even evidence you have found yourself. Your response was
“So here too is an invitation to think more fluidly about of evidence. Absence of evidence is not evidence of absence.”
That last statement is the eternal cry of every quack. It’s true, of course, but that does not mean that absence of evidence gives you a licence to invent the answer. But inventing the answer is what you do, time after time, You seem quite incapable of saying the most important thing that anyone in your position should. I don’t know the answer.
13 Responses to Half-baked nonsense in The Atlantic
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Prof Colquhoun,
Always await your blog entries with great anticipation and read with much pleasure, and this one didn’t disappoint. It’s humbling that you can so conclusively demolish the other pieces in the Atlantic, given only a 12 hour deadline! A characteristically uncompromising and unapologetic wading through the usual CAM nonsense, and dismantling of its baseless premises. I love it! I only wish I could write like this and to these deadlines.
I just wanted to add a perspective here from both pharma and the US, having moved over here from the UK a little over a year ago from UK academia to US pharma.
I had read much about the US as an outlier in the scatterplots showing an inverse correlation between religion and education level, but truly no statistics will prepare the uninitiated for the pervasiveness of religion here. Whilst the constitution ostensibly provides for a separation of church and state, I am astounded, on a daily basis, about how intelligent people can allow themselves to be so easily duped (currently reading Michael Shermer’s book on Belief to try to get some comprehension of it) – and that’s just here on the East coast! The delusional South remains ever more perplexing. I have found the US to be an incredibly welcoming and friendly place, and am very positive about moving here. But the overwhelming influence that religion has here, and the premises it fosters, of accepting unsubstantiated anecdote as fact, argument from authority, and the special, unquestionable status of faith that makes even the mildest of challenges offensive, I believe is at the core of the gate it opens to the similarly fabricated notions the CAM industry depends and thrives on. Breaking down the premises of religion, and the cultural protection it receives here in the US, is a daunting and enormous but necessary first step, before equivalent challenges can be made to the woo peddlers, who enjoy a comfortable, easy ride in religion’s slipstream. We need so much more of Dawkins, Hitchens, Harris and Dennett here!
My perspective on the transition to pharma is somewhat different, though I’m sure I’m not telling you anything you don’t already know when I say that I have found research in pharma to be no less rigorous than academia. Publication bias I believe is no better or worse, and the increasing interdependence between academia and pharma, I do think is making transparency ever greater and more difficult to avoid. Clearly, there is much work to be done, and the compulsion to publish negative findings is something we should continue to push for, for both scientific and commercial good. We have to overcome the human and financial pressures that lead scientists/companies to withhold data that detracts from their favorite theory, or would negate a commercial development. The pressures are different, but I hope it’s not too naive to say, no more or less prevalent – in my (limited) experience of both, at least. However, I often feel that pharma gets a disproportionately tough time for this. In my short experience in pharma, I have had to push academics to include data in a paper that was not to their liking (it had no consequence either way to any drug, since it was methods development study). I find fellow scientists in industry to be no more or less inquisitive, industrious, open-minded, knowledgable, or data-driven. I’m sure this is nothing new, and has been raised many times before, but I just thought worth adding again here.
Thanks again for your excellent article. Look forward to the next.
Your analysis is exactly right, and speaks to the difficulty in having not only the public, but professionals, maintain a rigorous, evidence-based and most importantly dispassionate and objective habit of mind, particularly in areas as emotionally charged as disease and death
Also, as a person trying to get research grants funded through the NIH, it is quite amazing how money is wasted on what is in essence anti-science.
@rleaguer
Thanks for your perceptive comments.
I don’t mean to come down too hard on pharma (though the temptation is always there to counteract the constants accusations from alt med people that I’m in the pay of big pharma), The fact is that it is pharma that does most of the discovery, and it’s also true that their trials are often very well designed. There have been some huge fines levied on pharma recently, but that is for the behaviour of their marketing departments, not their scientists.
Sadly, I have no difficulty at all in believing it when you say “I have had to push academics to include data in a paper that was not to their liking”. I have come across such problems myself in academia, more than once. They result partly from human vanity (unavoidable) but also from the excessively competitive publish or perish mentality forced on us by science administrators, and that is avoidable. In fact I worry more about the corruption of science by pressures like that than I do about quackery. I’ve written about it several times and always interested to hear about cases of cheating. For example there is the nasty business of the University of Sheffield, and the horrid phenomenon of ghost writing.
Thanks Prof Colquhoun for the well reasoned reply. I completely understand specifically your need to ensure that you apply, and are seen to apply, the same principles to pharma as CAM, and right you are to do so, of course. I can only imagine the number of ‘pharma lackey’ email accusations you must have to laboriously delete! Point accepted!
Since you raise it, I’d be genuinely interested to hear your thoughts on how science funding should be governed outside the ‘perish or publish’ model. Whilst I’d need absolutely no convincing whatsoever of it’s enormous limitations, to corrupt the old quote, is this not the worse possible system, apart from all of the other alternatives? Perhaps a topic for a future blog, or I’d be happy to see any links to previous blogs on this.
Enjoyed reading this, it was triumphant haha, very well written.
Alt-med traps of authority, anecdote, group identity etc do look exactly like typically religious behaviours. Interestingly (sadly), a friend of mine I used to discuss religion with critically, enrolled at some chiropractic college in Bournemouth (AECC) and is getting more and more religious about it by the day.
He fawns over quotes by the Palmers and seems to value “scoring points” for the team over logic in our debates. I find it so strange.
Medicine and a material view of the world are just scapegoats for them, in order to justify nonsense as if it were some kind of response.
How do such things happen to people’s mind, so quickly?
Tiege:
A feeling of incipient power.
I fear there is quite a lot of truth in that. Reading what the AltMed people write about themselves and their ‘crafts’, it seems to me that their utter lack of humility and their overweening self-importance often come across very strongly.
Real doctors have to train for an awful lot of years, are typically still under direct supervision and oversight for many years post-graduation, and are supposed to accept the possibility – indeed, the strong likelihood – both that a lot of what they do will be proved wrong, and that they will themselves make mistakes with consequences.
In contrast, the quacks spend less time (often far less) ‘training’, typically work in small private set-ups where they are unencumbered by supervision, and regularly allow themselves all the airs and certainties of the worst kind of caricature of an old-school surgeon c. the late 19th century.
Why they feel this compelling need to ‘play doctor’ is the question. The feeling of importance, and the power, that come with the role seem to be a big part of the answer.
I scoff the biggest scoff when I hear alt-med and religious types accuse scientists of arrogance!
@Aust
I agree. And doesn’t omnipotence and a feeling of powerfulness come with self-delusion? If you are self-deluded with special skills you think you possess aren’t you’re likely to seek an audience?
It’s one thing knowingly ripping vulnerable patients with voodoo medicine simply to make a profit, but I think many altmed practitioners feel that what they charge is commensurate with the ‘special skills’ they possess. It’s a form of self-flattery.
Knocking orthodox medicine is easy to do when you’re sensible as we all know things sometgimes go wrong, but it takes a particularly specious kind of self-delusion to think that medicine has totally losts its way.
As to comparison with religion, I remember our former local vicar describing fundamentalists as people who are sufficiently self-deluded to think that Go/Allah/Jehovah has favoured them over others (to the point where other’s lives are less valuable the theirs).
I’m infuriated by the smug, more-enlightened-than-thou narcissism of the New Age types. As an American, I see our society as quite self-serving, self indulgent, and overly self-entitled. The hoopla about “empowerment” just makes me want to hurl. And, of course, all this relativism this sets us up for religion and charlatanism. I’m just surprised that our ecocide is taking as long as it is.
Hey, DC.
David Katz has read your piece.
http://www.huffingtonpost.com/david-katz-md/questioning-the-guardians_b_884473.html
Methinks he doth protest too much.
@BadlyShavedMonkey
Thanks very much for pointing out that Huffington Post is, yet again, supporting nonsense medicine. There commenting system is useless, so I’ve replied above.
The rather wordy and grandiose reply Dr Katz has penned is quite revealing about him and about how he sees himself, I would say.
Reading Katz’s protestations it seems to me that many (most?) of his gambits (appeal to authority, ‘as a clinician’, ‘my patients’, ‘science doesn’t know everything’ ‘my open-mindedness makes me the real scientist’ – I’m paraphrasing, but you get the drift) match precisely what you get from (e.g.) the homeopaths.
DC certainly seems to have annoyed Dr Katz, anyway. Am I allowed to suggest we call his rather thin-skinned response “a Katz-flap”?