Homeopathy & Patient Choice: A rod for the PCTs backs?

July 27, 2010

Some brief thoughts on the department of health’s response to the homeopathy evidence check.

The predictably “hands-off” response [PDF] to the NHS using and funding homeopathy by the current administration potentially falls into a couple of obvious traps.

Whilst it ducks the thorny questions, in attempting to sate both sides of the arguments it has fallen between two stools.

Pro-homeopathy types will perhaps not be enamoured with the fact that the “evidence base” for homeopathy gets very short shrift, with homeopathy rightly being labeled as implausible and entirely placebo-based:

the majority of independent scientists consider the evidence for the efficacy of homeopathy to be weak or absent, and that there is currently no plausible scientific mechanism for homeopathy.

Those with an anti-homeopathy viewpoint maybe annoyed that the government ducked the decision on nhs funding, and palmed it off to the PCTs, citing patient choice.

the overriding reason for NHS provision is that homeopathy is available to provide patient choice.

This is a curious and illogical decision to make, and it has the distinct whiff of some “Duchy original” tinkering. I suspect that the department of health will shortly be inundated with FOI requests to determine if this was the case.

By ignoring the evidence base and going with “patient choice” the government opens the PCTs to all sorts of (perhaps) spurious requests.

Should cancer patients denied expensive therapies on basis of cost re-request them, citing their patient choice as a major and important factor? Should those wishing plastic or cosmetic surgery be allowed to get it on the NHS, as it is their choice? Should I get a case of Innis and Gunn oak-aged beer each month, as I find it relaxes me after a hard day’s work? At the tax payers expense?

Of course not – the NHS cannot and should not fund everything. But the first place cuts should have been made is on faddy magic pills that do not work (and, I concede, my beer…).

Should those wishing a quick and painless “assisted suicide” get it from the NHS, as it is their choice? Should a rather vocal minority with royal approval get worthless sugar pills with no medicinal value whatsoever?

The DoH response clearly states it does not wish to get involved in ethical discussions –

We note also that it is not for the Department of Health to comment on the ethics of the use of a particular treatment in a particular setting.

– yet it continues to hold a tough ethical & moral stance on the euthanasia issue.

To me, this response looks awfully like an attempt to fudge a decision which allows continued funding of homeopathy, despite overwhelming evidence that it does not work and is a pointless waste of NHS funds (although, as has been pointed out, there are other targets within the NHS budget in need of trimming).

When patients suffer due to lack of NHS funding, shouldn’t every opportunity be taken to trim away waste?

Mike Adams doesn’t understand basic high school immunology.

July 20, 2010

Mind-altering stupid from the self-proclaimed “Health Ranger”

Every science blogger needs a post poking holes in an article by Mike “Health Ranger” Adams – this is mine.

The setup.

Readers are directed to this recent article HIV vaccines cause 50 percent false positive rate in HIV tests, although, be warned: prolonged exposure can cause repeated palm-shaped imprints to form on your face.

Adams starts off by stating (correctly) that the standard HIV screening test, tests for antibodies against HIV, rather than the virus itself.

Well, yes. I am not sure why this is considered as surprising. The top result on google for “how does hiv test work” contains a pretty decent description including the phrase “it’s testing for HIV antibodies, not the actual disease.” Ah, the marvels of the internet, eh?

The US Centres for disease control has a more informative and perhaps reliable website HIV Testing Basics for Consumers, which under the tab “How do HIV tests work?” contains background information to the tests as well. So yes. HIV ELISA-based tests test for antibodies against HIV.

Every website I visited, UK or US, states that following the positive test with the ELISA kit, a further test (a western blot or possibly nucleic acid testing) is required to confirm the positive result. Which Adams doesn’t mention.

Adams also states “in some circumstances”  that the HIV test has a 50% false positive rate, but rates I’ve found are more like 1%. Adams doesn’t state what these circumstances are.

He then states that HIV vaccines cause upto 86% percent false positive rates with the HIV ELISA test. He even provides a journal in which this data is published – but obviously fails to provide us with a citation – that would be too much to ask. Here is it. It’s free.

It’s an interesting paper – and it contains data showing that vaccinating individuals against HIV causes those people to produce antibodies against HIV that cross reacts with tests designed to detect antibodies against HIV

This should not be a shock to anyone.

This is what your immune system does.

The first point to make is that 86% is the highest rate for a single vaccine causing cross reactivity (the adenovirus 5 type of vaccine).  The overall average level of “false positive” for all vaccine types and all ELISA test types was actually 42%. So that headline 86% figure Adams uses is misleading (check table 3 for a breakdown of the figures).

The cross-reactivity of the vaccine induced antibodies and the antibodies screened for in the HIV kit is not 100% – which again, is not particularly surprising. After all, there is more than one way to skin the proverbial cat – or in this case, for the immune system to recognise the HIV virus, and given that multiple types of vaccines were included in the study, this is to be expected. Different people, depending on their genetic makeup, will also produce different antibodies against different epitopes on the same foreign body – in this case the virus.

So some of the HIV-negative people vaccinated against HIV in clinical trials produce antibodies against HIV which cross react with the current first-line HIV ELISA tests. I don’t think this should be particularly surprising to anyone with a GCSE in Biology, unless they’ve changed the syllabus dramatically in recent years.

It is also worth mentioning that with the second line HIV test – of the ~40% of people who tested false positive,  ~10% percent of those also go on to test positive on the western blot test. So this is 92/2176 = 4.2% This number is not mentioned anywhere in Adams’ piece. (Table 5 in Cooper et al)

It is nice to have data published confirming this though, so hats off to Cooper et al for doing the leg work.

The Payoff.

So having built up a “case” that the *cough* HIV test is unreliable *cough*, due to cross reactivity with vaccines currently still in clinical trials, Adams then goes off on one, and goes for a wander around HIV/AIDS land throwing out “false-positives” in every direction:

1) He says that having tested HIV positive your life is altered in all sorts of nasty ways – no employment, no healthcare insurance, etc. Of course, he’s right, but he hasn’t mentioned the follow-up test. Not once. His 86% figure is misleading. This is essentially scaremongering – one would imagine that participants in a clinical trial would have that information on their medical records.

2) Fantastic quote – “We have already established here on NaturalNews that HIV / AIDS vaccines are medically unnecessary” – Brilliant – he should really tell some doctors and nurses though. This assertion is backed up by a quote from Nobel Laureate Luc Montagnier (he of the homeopathy fame – alarm bells should start ringing at this point) that “We can be exposed to HIV many times without being … infected. Our immune system creates [antibodies] within a few weeks, if you have a good immune system.”

Yes we produce antibodies, but HIV/AIDS get around them by being an AQUIRED IMMUNODEFICIENCY SYNDROME. Antibodies are only used to tag foreign objects for destruction by the immune system – antibodies are less effective at directing the immune system to kill viruses if there is no immune system left to kill the viruses! For more information – check out the wikipedia page for AIDS – it is as good a place as any to start, and is well referenced.

3) Western medicine causes disease instead of curing it –  a list of complaints about western medicine with not a single reference to back them up.

4) Finally – the money shot – links to clips of HIV/AIDS quack soft porn video, “House of Numbers”, and, oh yes, a link to somewhere when you can buy “House of Numbers” on DVD.

The conclusion.

Doctors are not infallible. Tests are not infallible. There are always going to be cases that slip through the net. The initial screening test has a false positive rate of roughly 1%. Of those that false positives, most will be shown to be false positives in the follow-up test. It is of course devastating for those few people who are misdiagnosed, and we must not forget that, but better that than having tests which have an unacceptable level of false negatives.

Those who participate in clinical trials are relatively rare and special cases – and should have the fact that they are participating in a clinical trial recorded on their medical notes.

But I think that the most important conclusion to this is RTFP – read the fine paper – and don’t trust Mike Adams’ interpretation of it.

(But hey! Don’t accept mine either – read the paper! This one is free!)

Frenkel rides again

July 2, 2010

Does peer-review need a peer-review? Or should skeptics be more proactive with scientific journals?

For those not in the know, Frenkel et al is an apparently peer-reviewed scientific paper from the MD Anderson cancer research centre, Texas, purporting to demonstrate that homeopathic ultra-diluted remedies (i.e. those with any active ingredient diluted to the point where the chances of finding 1 molecule of active ingredient is negligible.) can kill off certain cancer cell lines in the context of cell culture. Unsurprisingly, this paper has been widely toted by various pro-homeopathy websites, with cringe-worthy tag lines such as:

Skeptics May Have to Rethink Their Opinions–Homeopathy May Really Work

Sadly for homeopaths, perhaps rubbing their hands with glee at the prospect of an epic skeptic climb-down, the paper turns out to be garbage. As soon as the paper was obtained it was clear that the experiments and the analysis thereof were fatally flawed. In a nutshell, the homeopathic remedies were made up in high concentrations of extra neutral ethanol (as is often done). The ethanol concentrations were not controlled for, which essentially makes all conclusions invalid because ethanol alone, even at low concentrations, can have profound effects on cells. For more information see take-downs by Dr Rachie and Orac. It is also worthy of note that it appears that an unwitting author on the paper has come forward to also cast doubt about the conclusions in the paper:

“Therefore, I believe this study demonstrated changes in alcohol percentages on cells rather than the efficacy of homeopathic medicine.”

So – we have a journal article that even some of the authors express doubt in the findings of.

Frenkel himself has apparently left the MD Anderson cancer centre (Hat tip to @medtek off of Twitter for that one) , and has set up his own company integrated oncology consultants

The website of IOCs has all manner of woo within, from “superfoods” to “homeopathy for cancer”. It also indulges in a bit of bait-and-switch – it says stuff like:

“The main benefit that these treatments provide is improvement in quality of life and enhanced wellbeing. Rather than competing with conventional cancer care, complementary therapies are complementing conventional care as part of comprehensive cancer care.”

— and elsewhere directs you to the aforementioned Frenkel et al paper – which seems to be suggesting that Homeopathy can indeed compete with conventional cancer care.

However, given the fact that Frenkel et al has been published in a relatively obscure journal, and has really only been a debating point on skeptical and homeopathy/altmed websites, what’s the harm?

The most asinine man in UK politics.

Well – recently the paper resurfaced again, as it was mentioned in UK Parliament by conservative MP for Bosworth, David Tredinnick, as part of his proposals for an integrated healthcare bill.

“and the university of Texas has shown the positive effect of homeopathic treatments in killing cancer cells while maintaining good cells.”

Following this, Treddinnick proposed a slew of pro-homeopathy EDMs, which are once again, attracting signatures from the more credulous member of parliament. One of these EDMs deals specifically with the Frenkel et al paper.

Followers of woo in the UK parliament will be aware that it was Tredinnick who proposed Early Day Motion 908 which expressed concern with the scientifically robust conclusions of the Science and Technology select committee evidence check into homeopathy – EDM 908 was deliciously relabelled by Prof David Colquhoun as “A handy list of dimwitted members of parliament.

Evidence based Policy?

But can we really blame Tredinnick for using this paper in parliament? Personally, I am all for MPs referring to peer-reviewed papers in parliamentary debates. “Evidence based policy” was an idea floated by various parties in the run up to the election, which I ( and I think pretty much all skeptics) were broadly supportive of.

So can we castigate Tredinnick for quoting a paper, which he may have taken on good faith as being scientifically credible? Tredinnick has no scientific qualifications and, assuming he has read the paper, may not have been in a position to question its accuracy, methodology or conclusions. Assuming he has read the paper.

If he has not read the paper, then should he be touting it in parliament? Probably not, although I imagine an awful lot of papers, books and articles get mentioned in parliament, without actually being read by the mentionner.

So sadly, whilst it would be easy to dismiss this as Tredinnick rattling his woo-sabre, whilst this paper has not been retracted, we cannot really fault an MP for quoting it in parliament. However much we might like to.

The continued existence of this paper is a failure of peer-review.

Dr Michael Brooks, writing in the New Scientist suggests that (because of this incident) peer-review needs an overhaul. Whilst I agree that this paper needs retracting, I think that an overhaul of peer-review may be a little premature. Let us not forget that according to PubMed 848,345 papers were published in 2009 — it is inconceivable that a few duff ones wouldn’t slip through the net.

Also, the formal peer-review process is just the first rung of the peer-review ladder, albeit the most critical. Every time a scientist reads a paper, that is another instance of peer-review. A paper’s conclusions and methods should be critically appraised by every single reader — this is why the “methods and materials” section is perhaps the most critical section of any paper. Flipping straight to the conclusions section without understanding how the authors reached those conclusions is folly.

In a case such as this, where:

  • a paper is being touted to push unproven homeopathic therapies on desperate cancer patients,
  • two scientists (Dr Rachie and Orac) have carefully demonstrated that the paper is fatally flawed,
  • an author on the paper publically express concerns about the validity of the conclusions.

should we skeptics not take the fight to the journal editor?

After all, there is considerable overlap in the Venn Diagram of “research scientists” and “skeptics” sets. A letter to the editor of this journal, with suitable signatories, should produce the desired effect.

So… who’s up for writing that first draft?

EDIT: Minutes after posting this blog post 2 things happened:

  1. @JDMoffatt (himself a published scientist and academic) told me that he had, in fact, written to the editor of the journal in which Frenkel et al was published, but he hadn’t had a reply as yet.
  2. @JDMoffatt received a reply from the editor of the journal in which Frenkel et al was published.

The reply was rather unhelpful, and hardly the full and proper response that one might expect from a journal editor:

“Thank you for your comments. We are aware that the subject is controversial. We would be pleased to evaluate data (my emphasis) supporting your views if submitted”.

This is NOT how peer-review works. If someone has issues with a published paper, they write a letter to the journal (for publication) and this letter is given to the original authors to respond to (if they wish) and both letters are published side-by-side. The onus is not on the person raising issues to provide new data to refute it (although they can). They are not ‘disproving’ the original article – they are raising issues with the work within it. Grr.

On the issue of homeopathy EDMs..

July 2, 2010

The letter what I wrote to my MP regarding the mass of homeopathy related EDMs

(“Names have been removed to protect the innocent”)

I am writing to you to ask you to consider signing the following Early Day motions regarding the support of Homeopathy:

EDM 387, proposed by Peter Bottomley, MP.
EDM amendments 284A1, 285A1, 286A1 & 287A1 proposed by Julian Huppert, MP

To be clear on my point of view (and indeed, the scientific consensus) – Homeopathy does not and cannot possibly work.

It is pseudoscience and quackery of the highest order.

Homeopathic remedies are diluted to such an extent that not a single molecule of the “remedy” (which is often completely untested, unlike conventional pharmaceuticals) remains. Compare this with say, Paracetamol, where a standard 1000mg dose contains a touch under 1 million million milllion million (1 with 24 ‘0’s) molecules of paracetamol. Repeated clinical trials and meta-analyses have demonstrated repeatedly that homeopathic remedies perform no better than a placebo. Homeopaths however, have built up a ~£40 million industry (in the UK alone) that pushes these pills without a jot evidence for their efficacy.

For more background information – please see the science and technology committee evidence check report: http://www.publications.parliament.uk/pa/cm200910/cmselect/cmsctech/45/45.pdf

Whilst it is true to say that homeopathic remedies rarely have any side effects, a side effect of the lack of critical thinking that leads one to use homeopathy can be a failure to visit a GP to diagnose a potentially fatal disease. Recent examples of this include the tragic case of Pen Dingle in Australia, who died after she refused surgery to treat a case of stomach cancer which she would have had a very good chance of survival. Instead, she chose homeopathy and needlessly died, and in great pain. http://www.perthnow.com.au/news/nurse-tells-how-cancer-patient-penelope-dingle-was-writhing-in-pain/story-e6frg12c-1225880033776

Continued support and funding of homeopathy by the UK government and it’s agencies demonstrates a severe lack of critical thinking, and is most certainly NOT “evidence based policy”. It is an anachronism that the UK cannot afford to fund in the current climate – if people wish to use homeopathy and other alternative, unproven healthcare modalities, they should pay for it from their own pocket.

I have kept this message deliberately short — however, if you wished to discuss it in more detail please do not hesitate to e-mail or telephone me. I would be most happy to talk to you in person about this should your schedule allow it.

Kind regards…

There we go  – I decided not to address Tredinnick’s original EDMs one by one, for fear of going “tl:dr”, and because Julian Huppert has already done that in his amendments.

Updates will be posted as and when I get a reply.