Wrapped in Data and Diplomas, It's Still Snake Oil

New York Times book Review, By KATHERINE BOUTON Published: November 1, 2010

Ben Goldacre is exasperated. He's not exactly angry - that would be much less fun to read - except in certain circumstances. He is irked, vexed, bugged, ticked off at the sometimes inadvertent (because of stupidity) but more often deliberate deceptions perpetrated in the name of science. And he wants you, the reader, to share his feelings.

His initial targets are benign. Health spas and beauty salons offer detox footbaths for $30 and up, or you can buy your own machine online for $149.99. You put your feet in salt water through which an electrical charge runs. The water turns brown, the result of electrolysis, and you're supposedly detoxed. Dr. Goldacre describes how one could produce the same effect with a Barbie doll, two nails, salt, warm water and a car battery charger, thus apparently detoxing Barbie. The method is dangerous, however, because of the chance of getting a nasty shock, and he wisely warns readers not to try his experiment themselves. As for homeopathy, he says that it may indeed work but it's not because of the ingredients in those pills. You can pay for Valmont Cellular DNA Complex (made from "specially treated salmon roe DNA"), but Vaseline works just as well as a moisturizer.

There's more here than just debunking nonsense. The appearance of "scienciness": the diagrams and graphs, the experiments (where exactly was that study published?) that prove their efficacy are all superficially plausible, with enough of a "hassle barrier" to deter a closer look. Dr. Goldacre (a very boyish-looking 36-year-old British physician and author of the popular weekly "Bad Science" column in The Guardian) shows us why that closer look is necessary and how to do it.

You'll get a good grounding in the importance of evidence-based medicine (the dearth of which is a "gaping" hole in our culture). You'll learn how to weigh the results of competing trials using a funnel plot, the value of meta-analysis and the Cochrane Collaboration. He points out common methodological flaws: failure to blind the researchers to what is being tested and who is in a control group, misunderstanding randomization, ignoring the natural process of regression to the mean, the bias toward positive results in publication. "Studies show" is not good enough, he writes: "The plural of 'anecdote' is not data."

Dr. Goldacre has his favorite nemeses, one of the most prominent being the popular British TV nutritionist Gillian McKeith, whose books and diet supplements are wildly successful. According to her Web site, "Gillian McKeith earned a Doctorate (PhD) in Holistic Nutrition from the American Holistic College of Nutrition, which is now known as the Clayton College of Natural Health." (The college closed in July of this year.) Clayton was not accredited, and offered a correspondence course to get a Ph.D. that cost $6,400. She is also a "certified professional member" of the American Association of Nutritional Consultants, where, Dr. Goldacre writes, he managed to get certification for Hettie, his dead cat, for $60. Ms. McKeith has agreed not to call herself "Dr." anymore.

There's nothing wrong, he says, with the substance of her diet ("anyone who tells you to eat more fresh fruits and vegetables is all right by me") any more than with diets that advise drinking plenty of water and moderate alcohol intake and exercise. What he does object to is the "proprietorialization of common sense." Adding sciency flourishes and a big price tag to the advice may enhance the placebo effect, "but you might also wonder whether the primary goal is something much more cynical and lucrative: to make common sense copyrightable, unique, patented and owned."

Sometimes bad science is downright harmful, and in the chapter titled "The Doctor Will Sue You Now," the usually affable Dr. Goldacre is indeed angry, and rightly so. The chapter did not appear in the original British edition of the book because the doctor in question, Dr. Matthias Rath, a vitamin pill entrepreneur, was suing The Guardian and Dr. Goldacre personally on a libel complaint. He dropped the case (after the Guardian had amassed $770,000 in legal expenses) paying $365,000 in court costs. Dr. Rath, formerly head of cardiovascular research at the Linus Pauling Institute in Menlo Park, Calif., and founder of the nonprofit Dr. Rath Research Institute, is, according to his Web site, "the founder of Cellular Medicine, the groundbreaking new health concept that identifies nutritional deficiencies at the cellular level as the root cause of many chronic diseases."

Dr. Rath's ads in Britain for his high-dose vitamins have claimed that "90 percent of patients receiving chemotherapy for cancer die with months of starting treatment" and suggested that three million lives could be saved if people stopped being treated with "poisonous compounds." He took his campaign to South Africa, where AIDS was killing 300,000 people a year, and in newspaper ads proclaimed that "the answer to the AIDS epidemic is here." The ads asked, "Why should South Africans continue to be poisoned with AZT? There is a natural answer to AIDS." That answer was multivitamin supplements, which he said "cut the risk of developing AIDS in half."

"Tragically," as Dr. Goldacre writes, Dr. Rath found a willing ear in Thabo Mbeki. Despite condemnation by the United Nations, the Harvard School of Public Health and numerous South African health organizations, Dr. Rath's influence was pervasive. Various studies have estimated that had the South African government used antiretroviral drugs for prevention and treatment, more than 300,000 unnecessary deaths could have been prevented.

You don't have to buy the book to read the whole sorry story, which is readily available online. Dr. Goldacre believes in the widest possible dissemination of information. But if you do buy the book, you'll find it illustrated with lucid charts and graphs, footnoted (I'd have liked more of these), indexed and far more serious than it looks. Depending on your point of view, you'll find it downright snarky or wittily readable.

BAD SCIENCE Quacks, Hacks, and Big Pharma Flacks.By Ben Goldacre. Faber and Faber. 288pages $15

AIDS Denialism in South Africa: An Update (and book review)

by Ashraf Grimwooda

a Kheth'Impilo, Management, Cape Town, South Africa

published in the journal AIDS Care, Oct 9, 2010

South Africa has had the largest global HIV epidemic for close to two decades. The rule of democracy since 1994 did little to slow the exponential growth of this epidemic. The new leadership focusing all attention on matters of state-like economic disparity, poverty and unemployment amongst the previously disadvantaged, ignoring the warning threats of the oncoming plague of HIV by people like Peter Doyle. This was despite the National AIDS Convention of South Africa’s resolution reached by the ‘‘government in exile’’ and other civil society leadership in 1992, Maputo, to address the epidemic in a focused and urgent manner as soon as democracy is restored. Civil society was expectant, waiting for a response.

The then incoming Minister of Health Dr Nkosasana Zuma appeared to have a plan but soon she focused

on getting her anti-tobacco legislation through parliament, which she did very successfully. The extravagant waste of meagre resources on poorly thought through communication strategies on HIV prevention, as in this case, Sarafina II, unsettled civil society. This was exacerbated by the reluctance to institute AZT to prevent ‘‘mother-to-child’’ as undertaken by Thailand, a country with a lower GDP. The inappropriate support from government for the untested organic solvent Virodene as a major HIV treatment breakthrough, prior to any authorised research ethics committee or Medicine Control Council’s approval met with a huge public outcry resulting in the removal of a prominent professor of pharmacology, who refused to evaluate unethical data of this ‘‘research’’, from the MCC Board by the Minister. Dr Manto Tshabalala-Msimang replaced Dr Nkosasana Zuma as the new minister of health bringing with her a renewed sense of hope as she had supported the use of zidovudine in the prevention of mother-to-child transmission while in the Ministry of Justice, civil society needing a sense of hope in a country where there was the ever-escalating HIV antenatal survey figures. The country’s leadership was just not taking HIV seriously. Here was the ray of hope we were waiting for _ access to zidovudine for pregnant mothers, maybe there was the possibility of at least reducing mother-to-child transmission using evidence-based medicine.

Then in October 1999, I received a call while overseas from a journalist asking if I had heard that President Mbeki was questioning the science on the efficacy of zidovudine after having read counter arguments on the web. Back home there was a mad scrambling by civil servants to get evidence from sites where zidovudine was being used as to the adverse events and non-efficacy of this intervention. Soon in early 2000 this escalated into the questions from the President as to the causal link between HIV and AIDS, the specificity of the HIV antibody tests, the high rates of HIV positivity being a consequence of false or mis-readings due to the high rates of TB, that condoms were not effective against viruses like HIV, if they do exist, as the pores in the rubber latex were large enough to allow the passage of these viruses. The Presidential AIDS Advisory Panel was then setup to answer these questions, with a strong bias towards the denialist lobby, effectively stalling access to treatment and mother-to-child prevention for another four years. This had the greatest impact on the uninsured and unemployed who could not access any treatment unless through treatment trails undertaken by academic hospitals. Those wealthy enough to purchase antiretrovirals locally, or able to access treatment overseas were able to keep themselves alive from 1996 be that at a huge personal financial outlay. 

Despite the lack of support from the leadership, civil society lobbied and were able to move the Ministry of Health to developing the comprehensive Plan for HIV Treatment access which was adopted by Cabinet in November 2003 for the countrywide implementation. This also resulted in a significant drop in the cost of treatment further improving access to treatment for those insured. The President in the meanwhile removed himself from the ‘‘cause’’ to address the impact of HIV and AIDS. The schizophrenic approach from the Ministry of Health, where on the one hand antiretroviral treatment was being rolled out, reluctantly in places, and on the other the full commitment and support of untested ‘‘natural’’ therapies like beetroot, garlic and ubajane to name a few, resulted in a confused and somewhat patchy response to treatment rollout, negatively impacting on staff and patients alike. Some patients opted to stop or delay treatment with dire consequences.

Seth Kalichman’s Denying AIDS places these events into an international context quite successfully, pulling together the global network of denialists. Why did South Africa chose the path of denialism at this most critical stage where the epidemic was still in its acceleration phase is not clear. Was the agenda for political gain, financial or corporate support or was this due to a deep and private fear of knowing of one’s own risk and fear of the possibility of being positive? Was there a more sinister Malthusian agenda or a genuine mistrust of orthodox science? The analysis of techniques used through denialist journalism makes for interesting reading, especially the exploitation of individual fear and creating confusion through the morphing of science into technobabble. The author makes a strong link between the more common conspiracy theories and denialism and highlights some of the more prominent scientific minds supporting these. Why though begs to be asked, and is, but the answers are as complex as is this phenomenon. Was President Ronald Reagan (like leaders in China and Russia) of the denialist movement because he did not support evidence-based needle exchange programmes or was he being politically expedient by cowering to the religious right with their conservative and uninformed moral and punitive views on HIV?

This book focuses on the top tier of the social order of denialism, those who propagate the misinformation about HIV. Under these are those who gravitate towards denialism and conspiracy theories. In his own words, the largest section makes up the lowest tier and they are the ‘‘least visible and also most concerning’’, these being the patients with HIV, the recently diagnosed, grappling with the burden of knowing their status and what this means for the rest of their lives. This is an area that will need greater focus in future writings. With the appointment of the new cabinet after  President Mbeki led by President Jacob Zuma with the new minister of Health, Dr Aaron Motsoaledi, denialism is a non-issue at the top of the ‘‘pyramid’’ where there is the political leadership that can make or break the stranglehold of denialism as seen through the ages. There is a renewed sense of hope. The country is now poised to undertake the huge challenge to regain the ground that has been lost through the Mbeki years and improve access to prevention, treatment, care and support. Civil society is being mobilised to meet these challenges. 

On the individual level, where denialism is a form of coping with the reality of shock and grief, the care worker is constantly presented with an array of complex manifestations that need to be addressed to ensure maximum benefit from treatment. The newly diagnosed may find comfort in denial from time to time, as the challenges of living with HIV manifest. Addressing these very personal challenges of denial has not been the focus of this book although touched on. The care worker realises that individuals all have their own journeys through  oming to terms with this diagnosis, being there in a supportive way more than bridges this gap between denial and acceptance. The complexity of denialism at the top of the pyramid is though reflected through the rich text and solid research that went into writing this book where the author tries to find the root of HIV denialism and the reasons behind this phenomenon.

This well-researched book makes for interesting reading and diligently chronicles the events in the sad history of this epidemic, accurately highlighting the elements fitting for a Shakespearian tragedy. Recent events though in South Africa have shown how these can be rapidly overcome. There is though no time for complacency, more people need access to improved, cheaper treatment. Slipping back into denialism

and pseudoscience can recur again. Denial at the individual level presents ongoing challenges and addressing these in a creative way will always be the essence of care. There is no need for people in

leadership, be they from any sector (government or the religious sector), with their denialism conspiracy

theories to add to these challenges.