Chiropractors and naturopaths would like to be your primary care physician. They are tirelessly lobbying to expand their scope of practice, with the goal of achieving full parity with actual physicians. This would be an unmitigated disaster, for reasons I will detail below.

Oregon is setting up coordinated care organizations to help promote improved care at reduced cost. The idea sounds plausible and is a good experiment in how to reduce health care costs. The idea is to set up local groups of health practitioners who work in a coordinated way to take care of the local population, including physical and mental health, with dental health on the way. These CCOs would focus on preventive care with the goal of reducing illness and ER visits.

With any new health care initiative (including Obamacare, and this CCO initiative) so-called complementary and alternative medicine (CAM) practitioners see them as an opportunity to expand their power, reach, and scope. Unfortunately they have been largely successful – they know how to talk to both ends of the political spectrum, and the relevant science seems to get lost or distorted in all the propaganda.

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I received the following question in the topic suggestions page:

I recently got into a debate about the efficacy of bicycle helmets and — as someone who wears a helmet religiously and credits one with once saving me from serious injury — I was amazed to find that the research into this subject is… well, I’m not sure if “messy” or “inconclusive” is the right word:

http://en.wikipedia.org/wiki/Bicycle_helmet#Science:_measuring_helmet_effectiveness

Any insight you could provide into this would be much appreciated.

As with many things, the question is more complex than it may at first appear. It might seem at first that the question is straight-forward – do bicycle helmets work? But what exactly is meant by this? Most people might assume that this means – if you are riding a bicycle and get into an accident, will the helmet reduce the severity of the resulting head injury?

We could, however, ask several other reasonable questions related to using a bicycle helmet:

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David Colquhoun is a tireless supporter of science-based medicine in the UK. He has used freedom of information requests to great effect in exposing all sorts on nonsense and CAM-based mayhem. Most recently he has exposed a disturbing episode of politics trumping science in the National Health Service (NHS), specifically the website NHS-Choices which is a forum for educating the public about health decisions and empowering their informed consent.

Unfortunately NHS-Choices has recently fallen victim to politically pressuring with respect to their entry on homeopathy. In my experience most academic and government outlets for explaining medical information to the public do a generally good job – except when it comes to CAM, then they fail miserably.  There seems to be three main reasons for this. The first is that most academics and scientists do not understand pseudoscience in general or CAM in particular. They are simply naive about what it actual is and how it operates. Second (and deriving from the first), in such situations they are happy to turn over responsibility for CAM entries to the “experts,” which means proponents. Proponents will even convince the naive academics that “skeptics” are biased and their input should be avoided.

The third factor is the one apparently at work here – political pressure from proponents combined with the desire to avoid controversy. Giving the public accurate information about health care choices seems to get lost in the calculation.

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By now it should hardly be a news flash that smoking is bad for your health. What is interesting, however, is that the risks associated with smoking are getting worse over the last half century. For most of this time the health risks from smoking were greater among men than women – because men smoked more. However, a new study published in the New England Journal of Medicine, indicates that women have essentially caught up to men in this regard (probably not a form of equality they were hoping for).

The article traces trends in smoking-related health risks over the last 50 years. To summarize the finding – smoking increases the risk of developing heart disease, lung cancer, strokes, and chronic obstructive pulmonary disease (COPD). Those first three conditions are the number one, two, and three causes of death respectively (well, cancer in general, not specifically lung cancer). The new study tracks the relative risk of dying from all causes among current smokers and those who have never smoked. For lung cancer specifically they found:

For women who were current smokers, as compared with women who had never smoked, the relative risks of death from lung cancer were 2.73, 12.65, and 25.66 in the 1960s, 1980s, and contemporary cohorts, respectively; corresponding relative risks for male current smokers, as compared with men who had never smoked, were 12.22, 23.81, and 24.97.

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A recent article in Mother Jones discusses the potential role of lead in the increase in crime from the 1960s to the early 1990s, and the subsequent steady decline in crime rates since then. I have received numerous questions about this article and this possible connection between lead and crime. It is a well-written article, and an interesting question. Could one toxin really be responsible, among all the other possible causes, of the rise and fall in crime rates in the US?

Before we get to that, it’s interesting that this is not the first time in history this question has come up. There is a theory that the fall of Rome was due, in part, to chronic lead toxicity. The Romans used lead to make their water pipes (the origin of the word “plumber” as the root “plumb” refers to lead). But this was probably not the most significant source of lead for the Roman aristocracy, who also sweetened their wine and some of their food deliberately with lead. Analysis of lead levels in bones of burials from the time do show variable but often elevated lead levels, but the data is too scant to draw any firm conclusions.

They apparently knew of the toxic effects of lead, but thought that this was limited to acute lead toxicity – something that slave lead miners had to worry about, but not citizens. They did not think that low level chronic exposure was a risk, and apparently they were wrong.

However – there are problems with this nice story. Some scholars doubt that lead poisoning was as endemic in Rome as others claim. The evidence is complex. Lead was probably not added deliberately to wine, but wine was occasionally heated in lead containers. Terra cotta pipes were often used instead of lead for carrying water specifically because the risk of too many lead pipes was understood. And contemporary references in medical and veterinary writing make scant mention of lead poisoning, even though the syndrome was well recognized.

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I wrote last week about the problem of stem-cell quackery throughout the world, mostly in poorly regulated countries but with the purpose of attracting international customers. Stem cells are real, and the science of developing medical applications of stem cells is both real and promising, but these stem cell clinics are making claims that are years or decades ahead of the science. They are capitalizing on stem cell hype as a marketing ploy to those who are more desperate than scientifically savvy.

I was asked to comment on yet another example of the same phenomenon – nutrigenomics. That’s a very impressive-sounding name, just like a real science, but as always the devil is in the details. The claim is that by analyzing one’s genes a personalized regimen of specific nutrients can be developed to help their gene’s function at optimal efficiency. One website that promises, “Genetics Based Integrative Medicine” contain this statement:

Nutrigenomics seeks to unravel these medical mysteries by providing personalized genetics-based treatment. Even so, it will take decades to confirm what we already understand; that replacing specific nutrients and/or chemicals in existing pathways allows more efficient gene expression, particularly with genetic vulnerabilities and mutations.

The money-quote is the phrase, “ it will take decades to confirm what we already understand.” This is the essence of pseudoscience – using science to confirm what one already “knows.” This has it backwards, of course. Science is not use to “confirm” but to determine if a hypothesis is true or not.

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Stem cells are an exciting area of medical research. They are cells that have the ability to transform into different cell types, a property known as pluripotency. Some stem cells, such as embryonic stem cells, can turn into any cell type, which is called totipotency.

The hope is that researchers will develop the technology to harvest or create stem cells, manipulate their properties if necessary, transplant them into patients with specific diseases or damage, and coax the stem cells to fix, support, or replace the diseased or damaged cells. This is a potentially powerful treatment in theory, but is very tricky in practice. Researchers are still, in most cases, working out the basics of the technology – getting stem cells to survive and do what they want them to do, without growing into tumors or causing other problems. Researchers are making incremental advances, but are mostly in the test tube or animal research stage. For some indications they are making the first forays into preliminary human research.

Public awareness and interest in stem cell treatments, however, is way ahead of the reality. It takes years, perhaps decades, to innovate an entirely new treatment paradigm such as stem cell therapy. Unfortunately some unscrupulous clinics have decided to cash in on the premature hype by offering bogus stem cell treatment for serious illnesses. Most of these clinics are in countries with lax health care regulations and oversight, hoping to lure in wealthy and desperate foreigners. In fact, one of my first blog posts was about one such clinic in China.

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The off-label use of prescription drugs is often misunderstood by conflating it with the non-evidence-based use of drugs. I actually don’t have an issue necessarily with using drugs off-label. A distinct issue is whether or not drug companies can promote off label uses, and how they can advertise their drugs at all. A recent court decision may loosen restrictions on the pharmaceutical industry (and by extension the supplement industry and the marketing of any health product).

In a case that could have broad ramifications for the pharmaceutical industry, a federal appeals court on Monday threw out the conviction of a sales representative who sold a drug for uses not approved by the Food and Drug Administration. The judges said that the ban on so-called off-label marketing violated the representative’s freedom of speech.

The ongoing battle between regulation and free speech rages on. First for some background, in the US the FDA regulates the marketing of drugs, which are defined as a substance that is used to treat or modify any disease. Supplements are now defined as substances use to enhance or improve some structure or function in the body, but cannot be claimed to treat any specific disease. So these categories are based, for regulatory purposes, on the kinds of claims that are made for them.

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Both here and at Science-Based Medicine I and my co-bloggers often tackle health products that are marketed with unsupported claims. The pattern is now well established – the product is sold as a “supplement” so that it doesn’t have to deal with the pesky FDA, the claims are vague “support and enhance” nonsense, the products are generally good for whatever ails-ya, testimonials or worthless in-house studies are offered in place of peer-reviewed research, and the whole thing is cloaked in sciencey but meaningless technobabble. Some products are also sold through multi-level marketing (MLM), which itself is a highly dubious (if technically legal) practice.

It is very common, especially for products sold through MLM, for someone who sells the product to appear in the comments or to send in an e-mail defending the product. The tone is very different from the critical comments we get from “true believers” – the believers tend to be more angry and personal, while the sales reps speak in talking points as if they are reading from a brochure. The formula there is well-established as well. The same talking points pop up again and again, it’s all boilerplate.

Recently Harriet Hall wrote an excellent article at Science-Based Medicine about a product called ASEA, which is essentially salt water. Selling “magic water” is a great scam, and there are endless variations of it. There is a certain psychological appeal to water which makes it easy to believe it has healing properties. It’s also cheap, safe, and easy to distribute. Water, in a way, is the perfect snake oil – just add some pseudoscience. I won’t duplicate Harriet’s article, which covers the topic of ASEA well, but I will give a quick summary. ASEA is nothing but salt water. The company claims it has been treated with a proprietary process to create:

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Homeopathic logic is real logic that has been diluted into non-existence. The solvent is bias and propaganda. I was recently pointed to an excellent example of this – an article written by a homeopath arguing that homeopathy is superior to modern medicine. It’s published in what appears to be an obscure rag, but it does represent common arguments put forth by homeopaths so it doesn’t really matter.

Here is the main point of the article:

There are many differences in both the disciplines of medicines. Let’s just focus on one main difference and that is the fact that none of the homeopathic medicines introduced during the last two hundred and fifty years was withdrawn from the market.

The author, Asghar Ali Shah, uses the term, “allopathy” throughout the article. This is a derogatory term used mainly by critics of science-based medicine, and immediately reveals the author’s bias. In the statement above he is also trying to present homeopathy and mainstream medicine as two “disciplines of medicines,” which is a false equivalency. This is a common tactic of fringe beliefs, to appear as a viable alternative to the mainstream, followed, of course, by arguments for its superiority.

Homeopathy, however, is a prescientific superstition that is at odds with basic science, and not just medicine but physics, chemistry, and biology.

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