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More on Weight Loss

Fri, 02/23/2018 - 5:22am

Whenever I post about the topic of diet or weight management, there is always a lively discussion in the comments. There are also always many comments that are based on ideology, rather than evidence, and the level of emotion is significantly higher than for many similar topics.

I think this is because the topics of food, eating, and weight management seem very personal. Also, everyone has a lifetime of experience with eating, and so everyone feels like their own anecdotal experience makes them an expert (even if they intellectually know they aren’t). The topic is also a setup for confirmation bias – we all have many friends, co-workers, and family with their own dieting experience, and we can even look around and see what strangers are doing and how they look. It is therefore really easy to see the evidence for whatever your opinions are, to have the illusion that your beliefs are confirmed.

To add further fuel to the confirmation bias fire, there are a host of gurus and fake experts out there, and even genuine experts but who only see a slice of the science. There are enough expert and pseudoexpert opinions out there to confirm whatever position we want to take.

For all these reasons dieting is one of the more challenging issues for the average person to find objective reliable information. That is all I am trying to do here, adding my perspective as an advocate for science-based medicine. Interpreting scientific medical data is complicated, and there are lots of opportunities to be mislead. The weight-management literature is particularly complex and heterogeneous, so again, you can support pretty much any position unless you take a really careful look at the literature.

So to follow up my post from yesterday, which prompted a flood of different opinions, let’s take a further look at the evidence.

Why Basic Science Evidence is Unreliable for Clinical Claims

I frequently recommend that in order to resolve differences of opinion on factual matters it is best to establish common ground and solid premises from which to proceed. One of the frequent premises that results in differences in interpreting the medical literature is the relationship among the various types of scientific evidence.

One clear principle, that I have stated many times both here and at SBM, is that we cannot reliably infer clinical outcomes from basic science alone. In other words, we cannot study what happens in biochemistry, physiology, and to cells in a petri dish and then reliably make clinical claims about what will happen in people. The history of medicine is clear – we just can’t.

The primary reason for this is that the body is a complex web of interacting mechanisms. Predicting what happens when we pull on one thread of this web is like predicting the weather – with any complexity it rapidly become impossible.

Sometimes our predictions work out, but often they don’t because there is a compensatory mechanism in play. Our interventions may even have the opposite effect of what we want. Scientists predicted that alpha interferon would reduce inflammation in Multiple Sclerosis. It increased it and made the disease worse. Beta interferon, however, worked. Antioxidants were supposed to cure everything, but ended up curing nothing, because of all the homeostatic mechanisms in place.

Even when the direction of the effect is successfully predicted, we may not be able to estimate the magnitude of the effect. This is often the case, where the clinical claims are correct, but the effect is simply insignificant.

It is just not the role of basic science to determine clinical claims. Basic science helps us make hypotheses, to find new mechanisms, to know how plausible claims are, and to understand why things work the way they do. But clinical claims require clinical evidence – we always need to see what the net effect is of specific interventions.

Different Types of Clinical Evidence

There are also different types of clinical evidence and often these different types of evidence give different answers. There are observational studies, which have the advantage of looking at many people over long periods of time, but are not controlled. There are experimental studies, which have the advantage of controlling variables, but the trade off is that they are limited in size and often contrived and therefore hard to generalize to the “real world.”

Neither kind of evidence is perfect or gives us the final answer, but neither are they worthless. They can be used in a complementary way to infer the most likely answer.

What Strategies Work for Long Term Weight Loss?

With that as background, let’s take a look at what the clinical evidence shows in terms of what strategies are likely to be best for maintaining a healthy weight long term. We are also interested in being overall healthy long term, but if we go beyond weight management we will rapidly get way beyond what I can cover in one blog post. So I will only make general comments about overall health effects.

For the reasons I stated above, I am going to focus on clinical evidence in humans. The basic science informs the clinical evidence, but does not trump it. Also, animals studies are very difficult to extrapolate to people with things like diet. So I will stick to human clinical trials.

I also want to reinforce the question above – the goal is long term weight management, not short term weight loss only. One big question is – is calorie control more important, or is exercise more important? This is an endless debate, but I think the best current answer is – both.

Calorie restriction does result in weight loss, but also can reduce metabolism, reduce overall activity levels, increases hunger, and even cause depressed mood. You can blame evolution for this – it seems that our bodies interpret calorie restriction as famine, and responds by conserving calories and increasing hunger. When food is available, we want to pack on the fat stores to prepare for the next famine. This adapted us to pre-industrial life, but not our current stable abundance.

Exercise is a way to counter some of these effects. It can maintain metabolism, activity, help with mood, and also have other health effects like maintaining muscle mass. But – exercise also has a down side. Exercise alone is not a successful strategy for most people, and also can result in increased hunger, and compensatory decrease in baseline activity.

The best strategy appear to be both – moderate calorie restriction and moderate regular exercise maintains a caloric deficit (or balance if you are just trying to maintain weight) and mitigates the negative effects of each.

But again there are lots of ways to ask the same question. One study looked historically at physical activity and total calorie consumption by society to see the relative contribution of each to increasing obesity. They found that the dominant factor was an overall increase in caloric intake (not a decrease in exercise). In fact, the increase in calorie consumption was enough by itself to explain rising obesity levels.

The Characteristics of Successful Dieters

Another approach to the question is to look at people who lost weight and kept it off for a significant amount of time, and see what features they have in common. There are many studies looking at just this, and here is a recent (2016) review of what those studies have found:

However, many people report that they have successfully managed weight loss maintenance in the long term. Several factors have been associated with better weight loss maintenance in long-term observational and randomized studies. A few pertain to the behavioral area (eg, high levels of physical activity, eating a low-calorie, low-fat diet; frequent self-monitoring of weight), a few to the cognitive component (eg, reduced disinhibition, satisfaction with results achieved, confidence in being able to lose weight without professional help), and a few to personality traits (eg, low novelty seeking) and patient–therapist interaction.

The key factors that predict long term success are monitoring your caloric intake and measuring the net effect by weighing yourself regularly (once a week). People tend to underestimate their caloric intake, so tracking it helps. Also, the scale does not lie, so monitoring the effect is key.

But also, regular exercise predicts success. This fits the data I reviewed above about the effects of dieting alone.

Psychologically, support is very helpful. Shaming and negative emotions are detrimental. If people see the benefits of changing their lifestyle, they are more likely to keep it up. Confidence that they can lose weight, also helps. Using a buddy system is also of value – make the people around you your partners in your attempts at weight loss and maintenance.

Interestingly, while there are various results, there appears to be a consistent signal that a low fat diet is a better predictor of long term success than a low carb diet. These are uncontrolled studies, however, so it is hard to know how to interpret this. What is clear, however, is that low carb diets were not a predictor of long term success.

Low Carb vs Low Fat in Experimental Studies

This is where there is the most controversy – experimental studies where low carb vs low fat are compared head-to-head. Overall the results are very heterogeneous, and there are always lots of details to criticize if you don’t like the outcome. That was not low carb enough, or they had the wrong carbs, or they were or weren’t calorie restricted, etc. There are lots of study design choices that potentially affect the outcome, and the applicability to the real world is always doubtful.

But – having said all that, we can summarize the overall trends in these studies. I always go first to the most recent systematic reviews. This review concludes:

Both types of macronutrient-centered weight loss diets produced weight loss. Manipulation of macronutrient composition of weight loss diets does not appear to be associated with significantly different weight loss or metabolic outcomes.

However, other reviews conclude that low carb diets work better than low fat, so why the difference in reviews? Well, it depends on what features of the studies you think are important.

What the studies show overall is there, in the short term (usually six months) the low carb arm of the study loses more weight than the low fat arm. If you focus on this fact, you might conclude that low carb is better. It further seems that low carb produces less hunger than low fact, and that is often offered as the explanation for the benefit.

However, we can’t stop there. Longer terms studies, one or more years, give mixed results with the overall best conclusion that there is no real difference between macronutrient ratios. Further, overall weight loss is always modest. The charts also tell an interesting story in the long term studies, with all of the weight loss occurring in the first six months (where low carb does have a small advantage) but then subjects tend to gain weight and plateau, with either a small or no difference in ultimate outcome at 1-2 years.

How Do We Put This All Together?

That is the real question – how do we make the best recommendations from all the various kinds of evidence available. I think this study gets it right – they compared low carb to low fat diets for two years, but also with behavior intervention. Both groups lost equal amounts of weight at one and two years.

What I think the evidence shows overall is that, for long term weight loss and management, what matters is the behavioral and psychological aspects of eating and exercise, not the portion of macronutrients. I think the studies that find commonalities among successful weight losers is probably the best evidence we have.

Having said that, it also seems that there are many individual factors involved, mostly with personality, behavior, resources, and medical condition. So everyone has to take these general principles, and apply them to their individual lives.

And again, as I said, there are a host of other health issues dealing with diet, weight is not the only one. But there I think the consensus of evidence is that you just need to eat a variety of food with plenty of plants. Eat your vegetables. Don’t overdo anything.

I think obsessing with carbs vs fats is the wrong approach. The evidence simply shows that focusing on this factor does not help with long term success. At best there is a short term advantage, but that may actually be counterproductive, because it convinces a lot of people that low carb is the answer.

In any case, that is my reading of the evidence. I am open to other evidence and perspectives, but I would ask that you spare me your anecdotal evidence, spare me your personal attacks or conspiracy theories, don’t bother with the “more skeptical than thou” posturing, and just discuss the science. Please.

 

Categories: Skeptic

Low Fat vs Low Carb – No Difference

Thu, 02/22/2018 - 5:05am

There is a legitimate scientific debate about the optimal proportion of macronutrients (fat, carbohydrates, protein) for weight loss and maintenance. Although I do think there is a strong consensus that the scientific evidence supports the conclusion that the proportion does not ultimately matter (within a range of healthy balance), and that all that really matters is calories in-calories out.

Since weight loss is extremely challenging, even a small edge might be worth knowing about. There are also many basic science reasons to suspect there might be a difference in hunger for different diets, and this will translate into behavior. There are further many health considerations other than just weight and it would be good to know what effect different types of diet have on cardiac and diabetic risk factors.

Unfortunately there is a great deal of confusion and misinformation out there (common for any topic of public interest). One main drivers of this, as I see it, is a self-help industry looking to make billions on the challenge of weight loss by selling one fad diet after the other. Another main driver is the media reporting basic science or preliminary studies without putting them into proper context.

That is why one of the main goals of my science blogging is to emphasize that you cannot reliably make conclusions about interventions from basic or preliminary research. Most new ideas do not work out, and extrapolating from such data is not likely to lead to conclusions which are true. We need the research to develop to the point where we have rigorous clinical trials, testing the ultimate effect in actual people.

When we consider rigorous clinical trials of the effect of different diets on weight loss, there is a fairly consistent result – proportion of macronutrients doesn’t matter. Calories in-calories out is all that matters.

Now we have one more study to add to the list. Researchers compared a healthy low fat (HLF) diet to a healthy low carbohydrate (HLC) diet in 609 participants over one year. It is a decently large trial, conducted over a sufficient time, with good design. They found:

Among 609 participants randomized (mean age, 40 [SD, 7] years; 57% women; mean body mass index, 33 [SD, 3]; 244 [40%] had a low-fat genotype; 180 [30%] had a low-carbohydrate genotype; mean baseline INS-30, 93 μIU/mL), 481 (79%) completed the trial. In the HLF vs HLC diets, respectively, the mean 12-month macronutrient distributions were 48% vs 30% for carbohydrates, 29% vs 45% for fat, and 21% vs 23% for protein. Weight change at 12 months was −5.3 kg for the HLF diet vs −6.0 kg for the HLC diet (mean between-group difference, 0.7 kg [95% CI, −0.2 to 1.6 kg]). There was no significant diet-genotype pattern interaction (P = .20) or diet-insulin secretion (INS-30) interaction (P = .47) with 12-month weight loss. There were 18 adverse events or serious adverse events that were evenly distributed across the 2 diet groups.

As with most other similar studies, one main findings was that overall weight loss was modest, although 6kg (13 lbs) is not insignificant, that is not a lot of weight loss over a year. The second main finding was that there was no difference between low carb and low fat.

This study was also looking at whether or not subgroups with certain genotypes might respond to different diets (the who, eat right for your genes, thing) and found absolutely no correlation between baseline markers of genotype and effects of different diets.

No one study is the final word, but this is consistent with the consensus of clinical trials so far. When it comes to weight loss, the only thing that really matters is how many calories you put through your mouth and how many calories you burn. For most people (unless you can maintain an athletic schedule) we can assume moderate activity level (which includes regular moderate exercise). So really if your goal is to lose weight, it comes down to math.

An average person with moderate activity burns about 2,000 calories per day. There is 3,500 calories in one pound of body fat. So, if you consume 1,500 calories per day, you will burn 500 calories of stored energy per day, or 3,500 per week, which will translate into one pound of stored body fat per week. There is no escaping this math. There is no way to hack your body so that fat melts away, or that will override your body’s basic management of energy use and storage.

All of the basic science looking at hunger, hormone levels, insulin – all of that is interesting, and may have a minor or temporary effect, but none of it trumps the basic reality of calories. They translate into insignificant effects that can be comfortably ignored. In fact, they are a distraction and focusing on things like macronutrient balance will take your eye off the real ball, the calories.

Weight loss, ultimate, is simply math. However, this does not capture the real challenge of weight management, and that is hunger. We evolved mostly in conditions of limited caloric resources. We are evolved to pack on the stored calories when we can.

In fact, a recent study confirms the finding that after weight loss our hunger increases. Our bodies respond as if we just went through a famine, and so we better pack on the fat while we can to prepare for the next one.

This is why most diets fail long term. Counting on 24/7 will power is a difficult strategy that most people cannot pull off. It is a setup for failure. What predicts long term success is making permanent changes to your lifestyle that are sustainable. Don’t count on will power, for example, have low calorie food (and not high calorie food) in the house for snacking. Change your ordering habits when you eat out. Change your perception of how large a portion is appropriate.

More importantly, find your problem areas and come up with ways to fix them. People have different behaviors, social situations, and resources, and so think about when you consume the most calories and think of ways to mitigate it that you can live with indefinitely. Weigh yourself every week, estimate your caloric intake, and keep people close to you in the loop so they can support you. All these things predict success in long term weight loss.

But don’t think that just changing the balance of macronutrients, or going on that fad diet, is the magic answer. If you do you are overwhelmingly likely to have short term success and long term failure, because you didn’t make permanent changes to your behavior.

And definitely exercise to keep up your muscle mass, metabolism, and for overall health. But don’t expect to lose weight solely by burning more calories. This strategy doesn’t work. It helps, but you need to have portion control to make the math work.

Finally, don’t plan on losing weight quickly. That is not healthy or sustainable. You are better off planning on slow but steady weight loss – 1 to 1.5 pounds per week, for example. This also predicts success.

The good news is there is a lot of research in this area and we actually have lots of helpful information that predicts success in long term weight loss. The bad news is that most of the information out there is not science-based. It is based on selling self-help books, magic diets, and wishful thinking.

Categories: Skeptic

Superbrain Yoga is Still BS

Tue, 02/20/2018 - 4:47am

In 2015 I wrote about a new fad called Superbrain Yoga (SBY – I suggest just reading that article for background). This one is pure pseudoscience – silly and ritualistic movements are used to increase “prana” energy (which is make-believe) and thereby increase mental energy and focus. There is, of course, no credible evidence to support such claims, and no scientific plausibility.

Even though that is an old article, a comment just appeared proclaiming: “Please do some research before you call things a hoax,” followed by four links to alleged evidence that SBY works. One of the links is dead, but the other three refer to studies published in 2016 and 2017. Since my article was written in 2015 it seems unfair to admonish me for not researching future publications.

In any case, it seemed like a good opportunity to update my article on SBY with the new research. As you might have guessed, the articles don’t show what the commenter apparently thinks they do. In fact they are excellent examples of pseudoscience, displaying many of the features I have complained about over the years.

One article looks at alpha wave activity on EEG. The second studies hyperactivity in children with ADHD. And the third looks at memory and attention in children. All three studies share a number of features which makes them less than compelling as evidence. First, they are all published in low-rent journals, such as the Indian Journal of Traditional Knowledge. They may have a slightly biased editorial approach over there at the IJTK. But let’s look at the studies themselves.

All three studies take a “pre-test, post-test” approach. In fact the second study describes itself as “quasiexperimental.” You might wonder what that means. None of these studies are controlled at all – there is no control group. They essentially took a group of children, tested them in some way, then did a bunch of interventions and tested them again. It is completely unsurprising that there was a difference post-test, and it is entirely established that such uncontrolled “quasiexperimental” observations are essentially useless as evidence.

There are a number of reasons we do not rely on uncontrolled observations such as this. There is an experimenter or observer effect (sometimes called the Hawthorne effect). Just being observed is likely to create a change in behavior and subjective reporting. Imagine children being told to do these special exercises by enthusiastic adults, and then tested on effort-dependent performance. You think the kids might be trying a bit harder in the post-test situation to please the adults?

Unblinded evaluators are also notoriously biased. It is incredibly easy to essentially see what you want to see.

To put the bias of the experimenters into context – in the third study they also measured “pranic energy.” What is “pranic energy?” It is a made up “subtle” energy that is supposed to improve health and mental function. There is no evidence that it actually exists, an no theory to support its existence. Yet the researchers claim in the study that they measured pranic energy “using a scale.” That is the extent of the description, which left me wanting more details. I wasn’t even sure if by “scale” they meant a physical scale, like one used to measure weight, or a scale like a numbering system. In either case, how the pranic energy is detected and quantified is not described.

Of course, if these researchers could objectively detect and quantify a new type of energy important to biological function, there are some Nobel Prizes in their future. One might argue that they are burying the lead in this study, if they are really able to do that. Alternatively, it is possible that one or more of the researchers just felt the pranic energy and proclaimed it to be whatever they wanted. This is like using a psychic to communicate with time-traveling aliens.

There is also the ever-present concern of p-hacking – subtle biases in data collection and analysis that can create a significant outcome out of noisy data. P-hacking is maximized with small studies, subjective outcomes, unblinded evaluations, and biased researchers. I think all those boxes are ticked here.

All the studies also acknowledge in their discussions  that exercise is known to have an effect on mental function. I agree – exercise is good for the brain. So again we see the fallacy of designing a study so that a non-specific effect can be interpreted as a specific effect. In this case, the effects of exercise in general are being used to create the appearance of an effect from SBY specifically.

Taken together we have a perfect storm of pseudoscience. These studies are not designed to determine if SBY is a real thing with a real effect. They are designed to create the false impression that something is happening with SBY, via observer effects and other non-specific effects, such as from exercise in general. They are small, observational, not blinded or controlled in any way, make free-wheeling claims about magical energy, and are published in fringe journals.

But apparently they had their intended effect, which was not to do actual science but to create the veneer of science. That is what pseudoscience is all about. At least this one commenter was sufficiently bedazzled by this crap science to think it countered my thorough analysis of why super-brain yoga is entirely BS.

Categories: Skeptic

Brain Plasticity in Infants

Mon, 02/19/2018 - 5:09am

A new study looks at the brains of young adults who suffered a stroke in the language center of their brains as infants. They found that the subjects developed normal language, which just relocated to the mirror-image other side of the brain. This is not surprising, and reflects our evolving understanding of how the brain develops and functions.

For most people language localizes to the left frontal and temporal lobes of the brain. Broca’s area in the frontal lobe is involved in speaking, in the subtle motor output necessary to precisely articulate words. Wernicke’s area is in the temporal lobe and is involved in translating words into ideas and ideas into words. The two areas are connected by the arcuate fasciculous. These are the central language areas. There is also surrounding cortex which is necessary for communication between the language structures and other parts of the brain.

For most people the language area is on the left side of the brain. Meanwhile, the mirror right side of the brain is involved with understanding and producing speech intonation – knowing when someone is asking a question or being sarcastic. The right side is also involved with music and singing.

We also know that brains are plastic, meaning they can change the structure of their connections as necessary. People often use a computer analogy when talking about the brain, but the analogy to digital computers is flawed. Computers are hardware that run software, but brains are neither hardware or software – they are wetware, which is both at the same time. The connection of neurons in the brain is where information is stored and processed, and those connections change as a result of the processing, which alters the memory.

In addition, not just the connections but the anatomy can change in response to use and need, but in a constrained way. The brains of people who play the violin from a young age are different – the part of their cortex that controls their non-dominant hand, the one that works the strings, is hypertrophied.

This new study fits into this model and extends it. The researchers found that the subjects with a dominant hemisphere stroke as an infant developed normal language, but still has a bit of a limp or decreased motor function on their dominant side. Imaging showed that their language function had relocated to the opposite hemisphere, but in the mirror locations.

These findings reflect several concepts important to our understanding of brain function.

First is the basic concept of plasticity itself, the ability of the brain to alters its structure with use and demand. Plasticity is maximal as a fetus or neonate, and then decreases as we age, although never going away completely. Further, there appears to be developmental windows with maximal plasticity for certain functions (including language). For example, you need to develop the wiring for binocular vision by a certain age.

Plasticity is also limited by the parts of the brain involved. It seems that only the mirror cortex can take over language function, not other parts of the brain. In some people, after a language area injury, other parts of the cortex will become more active during speech, but they will not function as well. They are trying to compensate, to take over some of the lost function, but they are just not organized for speech.

Putting all of this together to give us a view of how the brain probably works – it seems that the brain is not a uniform mass of neurons, but is anatomically divided into discrete areas and networks with different kinds of neurons connected in specific ways. Some scientists refer to these basic structures as brain modules, which are connected in brain networks.

But these modules and networks are only semi-specific. They are optimized for a certain kind of processing, but that processing can be used for many different specific functions, and can participate in many different networks.

This explains why language relocates to the opposite hemisphere. It now seems that when language develops, both hemispheres have language capable cortex in the frontal and temporal lobes. The two hemispheres then divide up the work, with words and articulation going to the dominant hemisphere, and emotional content and music going to the other. They subspecialize, but both have the basic architecture capable of language. So when the primary language cortex is damaged, the other hemisphere has the function necessary to take over. The visual cortex, however, has a very different structure and could not function for language.

We might see the cortex as having at least three layers of specialization when it comes to the structure of the neurons and supporting cells that determine function. Cortical neurons have a basic structure that determines the kinds of processing they can do. With development, appropriate cortex is adapted to whatever functions are necessary, essentially determined by use. That function is then coded with the specific details of your environment, including culture and family.

So, for example, the language area has the capability of developing language function, but will only do so if a child is exposed to language. Further, the language area will reflect the specific language or languages learned. It will learn the phonemes and grammar of the primary language to which a person is exposed.

All of this reflects the fact that brains are an adaptation specifically to quickly adapt an organism to the environment. Brains learn, they change, they remember – all of which gives the ability to adapt dynamically to changing behavioral needs.

This is why it is misleading to talk about a brain being “hard-wired” for some behavior. That is not how the brain works. But neither is behavior entirely learned. The old nature-nurture debate has been resolved – the brain is both. That’s kind f the point.

Evolution, genetics, and development determine the basic structure of the brain and the kinds of processing the brain can perform well. This translates in a person to their propensities, their talents, their strengths and weaknesses. But all of this interacts heavily with the environment – what they do and what they learn. People can change, learn, and adapt at any age, however it does become more difficult as we get older. Also, deeply learned patterns at a young age may be very difficult to change.

Also, some aspects of personality seem to be more genetically and developmentally determined than others. We are born with a personality, but again we can look at it like a general propensity that can manifest in many different specific ways determined by environment. So we are not blank slates, but neither are we the slaves to neural destiny.

This kind of research, in addition to giving us insights into healthy neurological function, may also help us treat patients with various kinds of brain injury. How can we optimize plasticity, and improve recovery? Is it possible to de-specialize a part of the brain so it can take over a different function? Perhaps not, but it’s an interesting idea.

Also, this kind of knowledge will be key to developing brain-machine interfaces. We need to know what kind of processing the brain is doing. We may be able to make brain prosthetics that take over for lost or damaged brain functions. As we develop neural-net computer chips, understanding how the different parts of the brain are fundamentally organized and how that relates to their function will be important.

Categories: Skeptic

More Victims of Alternative Cancer Treatments

Fri, 02/16/2018 - 5:10am

Every doctor who treats cancer patients can tell you stories of patients who present with cancers too advanced to treat because they were spending their time pursuing alternative treatments. This has also been studied – last year a Yale team published a study showing higher rates of death among cancer patients who choose alternative treatments.

There is now a recent story of a YouTuber who produced videos claiming that a vegan diet and prayer cured her stage 4 cancer, except now she has died from her cancer. Of course, I am sad for her death and that the treatments she sought at the end were not enough to save her. It’s likely that everyone knows someone affected by cancer – it is a scary and often tragic disease. At the same time, we can’t miss the lessons in this story. It is so typical it can serve as an archetype.

What typically happens is that when some people are diagnosed with cancer they search for any possible salvation from their situation. That is understandable. Often there is an initial treatment, such as removal of a solid tumor, or shrinking the tumor with drugs. Some patients may also seek additional intervention, such as alternative treatments or faith healing. At that point they are in the honeymoon phase of the illness – no matter what their ultimate prognosis, their symptoms were likely improved by the initial treatment. They can imagine that they are cured. This is usually the point at which they claim that whatever alternative or faith-based treatment they underwent healed them.

Depending on the type of cancer, some of these patients may have been essentially cured by their initial surgery or treatment. For those who weren’t, a recurrence of symptoms is inevitable. We then may or may not hear about them when the cancer returns and leads to their death.

What this means is that newly diagnosed cancer patients can find countless stories of people claiming to have been “cured” of their cancer by all sorts of nonsense. There will always be a cohort of people in the honeymoon phase of their illness. This is the pitfall of anecdotal evidence. It is selective and biased.

What we really want is a systematic assessment of what the result of various treatment choices are. If you have a specific kind of cancer, and you choose the recommended treatment regimen what will be your outcome, statistically? What are your chances if you delay or refuse treatment, or if you rely on various alternative treatments? Well, we have this data – if you rely on alternative treatments your chance of death is increased.

The story of Mari Lopez, linked to above, follows this typical pattern. She became a popular YouTuber with her niece, Liz. Together they claimed that juicing, a vegan diet, and prayer cured Mari’s stage 4 cancer. When Mari’s cancer returned, she understandably became depressed. She asked Liz to take down the videos claiming she was cured, but Liz refused. She has doubled-down on her claims in the face of such dramatic evidence to the contrary.

How is this possible? The power of a strong narrative. Just read the comments below the article and you will see a typical battle of world views. The evidence is mostly irrelevant, because you can simply filter the evidence and choose whatever your reality is.

If find it instructive that Mari and Liz mixed together the claims that diet and faith cured Mari. Both, in fact, are manifestations of faith. Alternative medicine is often a mixture of pseudoscience and faith healing, blended seamlessly together.

The faith claims have a significant problem with logic and consistency. I don’t begrudge anyone their personal faith, but I do think it is counterproductive to depend for anything important on a mythical being you just hope exists. What I always find intriguing is those who claim that God cured them of a disease, but not really. In this case Liz believes that God cured Mari of her cancer, but Mari wavered, so the cancer came back and killed her. Really?

First, that is a pretty incompetent cure. I would expect more from an omnipotent being. The other implication, if you are going to give God credit for the cure, then he has to get the blame for the return. That means that God smote her, struck her down with cancer because she had a hamburger.  You can draw your own conclusions about what kind of god would do that.

Liz’s current rationalization for Mari’s death, which seems to contradict her entire YouTube career, is that toward the end Mari was cheating on her vegan diet. You see, the juicing was only just keeping the cancer at bay (which is why they claimed she was completely cured). The moment she started to waver in her vegan purity, and gave in to the temptations of beef, the cancer claimed her.

This is another absolutely typical part of the faith healing narrative, borrowed heavily by the alternative medicine narrative. Failures are always blamed on the patient. It is a convenient rationalization – they lacked sufficient faith in the case of the former, and they did not adhere fanatically enough to the regimen, for the latter.

That is often the extra layer of cruelty imposed by alternative cancer cures. First, target someone who is extremely vulnerable because they were just given a scary diagnosis and face months or years of horrible treatment. Lure them away from logic and evidence with the promise of salvation. Turn them against the doctors who are trying to give them objective evidence-based advice. Convince them that their doctors are just money-grubbing shills for an evil industry of death.

Now that you have them in your clutches, suck every ounce of money out of them you can. You can maximize your profits if your victim is willing to raise money from family and friends. Cancer patients are very sympathetic and good as props for fundraising.

While they are busy raising money to pay you, make sure whatever time they have left will be spent pursuing a draconian treatment regimen – consuming massive amounts of raw vegetables, and getting coffee enemas, for example. This may seem unnecessarily cruel, but this is important. When their cancer returns you can then blame them for not following the impossible regimen strictly enough. This is the best way to deflect any blame for the bad outcome. They will be too busy feeling guilty as well as depressed.

This may seem like a dramatic story, but it is literally true in many cases. Not all alternative treatments are this cynically bad or extreme, but this is not uncommon, and most will incorporate some of these features.

Yes, mainstream treatment is expensive and harsh too. Cancer is a serious disease and often requires aggressive, even desperate, treatment. The difference is, mainstream treatments are based on a thoughtful analysis of the best evidence available, and patients are given detailed informed consent. Alternative treatments are a package of lies, pseudoscience, false hope, and deception. But they are wrapped in a compelling narrative (if it fits your world view).

So Liz thinks that Mari was killed by her backsliding on her juicing and vegan diet, and that God reneged on his miraculous cure. That is apparently easier than questioning her alternative medicine narrative. I can understand that – because that would involve facing the fact that delaying conventional treatment while putting her faith in juicing may have contributed to, and even lead to, Mari’s death.

It is important to point all this out, not for Mari (her story is over) and not for Liz (who is probably a lost cause) but for all those other recently diagnosed cancer patients out there. Facing a cancer diagnosis requires a bit of courage, and a lot of support. False hope and deceptive but alluring narratives literally kill. Many cancer patients will also tell you that after their diagnosis well-meaning friends, family, coworkers, and other acquaintances come out of the woodwork to offer their completely unsolicited medical advice.

Here is my advice – don’t do this. Just stop. You are not a doctor, not an expert, and your Google university degree does not mean you can practice medicine.  The person you are trying to help either will be harmed by you, if they follow your advice, or at best will be extremely annoyed. You are just adding emotional pain to their situation. They don’t want the guilt and pressure of being told that they need faith, or they need to keep a positive attitude, or they need to start juicing and avoid meat.

Stop it. You don’t know what you are talking about. You are just causing pain and harm, despite your intention. Just give them love and support, and let medical professionals take care of the rest.

Categories: Skeptic

The Neuroscience of Virtual Reality

Thu, 02/15/2018 - 5:10am

A couple months ago I received my first virtual reality (VR) headset, and have been experimenting with various games and apps since. (Here is my initial review.) As a neuroscientist, it is a fascinating demonstration of how our brains construct our experience of reality.

What I and everyone who has used my gear has experienced is surprise at how visceral VR can be. It’s just a big video, right, so why do our lizard brains react so strongly? The most dramatic example is an app called “The Plank Experience”. In it you take an elevator up to a high floor in a skyscraper. The door opens to reveal a plank going out over the street far below. Everyone so far is frozen at the moment the doors open and they see the chasm below them. Some can walk out onto the virtual plank, but most people hesitate and at least one person bailed and would not do it.

What is interesting is that when I stepped out onto the plank, I completely 100% knew that I was standing on the carpet in my office, totally safe and at no peril at all. However, the part of my brain that knew I was safe was in conflict with a deeper and more primitive part of my brain that was screaming, “Danger, danger.”  It took an effort of will to overcome the fear, but I could not make the fear go away.

Let me describe one other part of the VR experience and then I’ll discuss what is going on neurologically. Motion sickness has been a major challenge for VR. All of the games and apps I have used so far have an option (usually the default) where if you have to move your character in the VR world you do it by teleporting. You use the control to place an X on the floor where you want to go, and then you are instantly in that location. This type of movement does not produce any motion sickness.

However, in some games it is possible to “run” through the world. With any kind of continuous movement of my avatar, even a little, I am instantly motion sick. I essentially cannot tolerate this kind of movement. People apparently differ in this regard, but mostly as a matter of degree. VR developers have not been able to make the problem go away through technical fixes, such as resolution or visual tricks. They essentially just had to provide other ways of moving in the VR world. (Companies are still working on other options, but nothing is out yet.)

Both of these aspects of VR stem from the same neurological phenomena. You can understand them if you understand that your experience of yourself and the world are completely constructed by your brain. You don’t directly experience your sensory input. Rather, that input is filtered, altered, analyzed, compared, and then finally constructed into a seamless experience.

For many sensory constructions there is a threshold effect – your brain essentially makes choices of how to construct sensory streams, and once those choices are made, the construction snaps into place. It is often an all-or-none phenomenon.

This is most apparent with common optical illusions. One class of optical illusion derived from ambiguous stimuli. Are you looking at a rabbit or an old woman? Is the girl spinning to the left or right? Is the box pointing up or down? Your brain will construct the image one way or the other, but not both, depending on assumptions about what is foreground, what is background, orientation, and shading.

Other illusions are pictures that are right at the threshold of our brain’s ability to construct the apparent image. Snow and rocks can instantly turn into a picture of a dalmation, and once you see it, you cannot unsee it. The construction is in place.

Even more interesting is that part of this construction of your perception of reality that your brain does includes a perception that you exist, that you occupy, own, and control your various body parts, and that you are separate from the rest of the universe. These components of your experience are actively constructed, and can be disrupted.

Part of these constructions involve another phenomenon mentioned above – your brain compares the various sensory streams. It also compares them to other processes in the brain, such as your intention to move. For example, your vision indicates your relationship to your surroundings and whether or not you are moving. Vestibular sensation senses movement and orientation to gravity. These two sensory streams should be telling the same story – your brain expects to see and feel the same movement at the same time. When these two sensory streams do not match, you feel motion sick.

That is what is happening dramatically with VR. You see yourself running through the virtual landscape, but your vestibular system feels you are standing still. Teleporting gets around this because you don’t see yourself move, you are just instantly in the new location. Your brain processes smooth movement different than sudden jumps. It’s possible this is due to the fact that we don’t teleport in the real world, and so our brains would not be adapted to experience it. But also, our eyes have both smooth pursuit and sudden “saccadic” movements. Our eyes can jump from one target to the next, and when we do this we don’t become disoriented. Our brains suppress the sudden change. Perhaps our brains treat teleporting in VR like saccadic eye movements.

Turning back to the visceral experience of VR, this is likely also similar to an optical illusion. Just like you cannot unsee your brain’s construction of ambiguous stimuli, you cannot convince the subconscious part of your brain that you are not standing on a plank 40 floors above the street.

The visual system does not only construct what it thinks it is seeing, but then it also connects the resulting construction to other parts of the brain that trigger memory and also emotion. The visual stream connects directly to the limbic system, assigning emotional significance to what you see. You feel love, hunger, anger, or fear automatically based on the visual stimuli.

Further, the more sensory streams that are involved in an experience, the stronger the construction. VR systems, obviously, include sound also. So you hear the wind whistling by your ear, and that contributes to the illusion you are in danger of falling to your death. Blow a small fan in the face of someone walking the virtual plank, and the illusion becomes more powerful still.

I experienced this type of illusion in some of the newer them park rids. The Spiderman ride in Universal is essentially virtual reality, but instead of wearing goggles they use large screens built seemlessly into the environment. They use small movements of the car you are sitting in to simulate the car falling off a building and careening through the city. At one point you are faced with a villain with a large blow torch, and you are met with a blast of warm air which totally sells the illusion.

To illustrate the power of multi-sensory illusions (and the fundamental nature of our brain’s reality construction) there are experiments in which people sit at a table. One arm is on top of the table, while the other is below and covered by a sheet. There is a fake arm on top of the table where the real arm is hidden. All it takes is for someone to touch the fake arm while also touching your real but visually hidden arm – you see and feel the fake arm being touched. The alignment of these two sensory stimuli is enough to convince your brain much of the time that the fake arm is actually part of your body.

Our brains also compare our intention to move with sensory feedback (visual and proprioception) that indicates we actually have moved, and this creates the sensation that we control our body parts. The construction is also easily broken if these two streams do not match, or one is disrupted. This results in what is called “alien hand syndrome” – the sensation that your body part is not under your control.

What all this also means is that we can easily trick the brain into constructing reality so that you occupy and control a virtual avatar, and that you are living in the VR world. It will be real to you – just as real as the plank.

The visual part of VR is now above the waterline – it is good enough to convince your brain that it is real. Incremental advances will be nice, but the technology has arrived. What VR developers are working on now are the other senses. Haptic feedback means giving sensory feedback to match what the person sees. So if you touch a virtual object, the haptic glove you are wearing gives the sensation of touch to match. Others are working on ways to fool the vestibular system to sense the movement you are seeing. This would fix the motion sickness problem, but it remains to be seen if they will succeed. One company, for example, is working on a system in which you control your movement by moving your head and body. Tilt your head forward to move forward. I will be interested to see how well this works.

The bottom line of all this is that – our brains construct our experience of reality, and it is possible to hack that construction to fool the brain into believing that you are operating in a virtual reality. The experience, as primitive as it is, is already profound, and will only get more so.

Categories: Skeptic

New California Initiative – Crank Magnetism in Action

Tue, 02/13/2018 - 5:06am

Being involved in skeptical activism for over two decades does provide some perspective. One phenomenon I have noticed is that most pseudosciences and weird belief systems are, at their core, the same. Sure, the details vary, but the underlying errors in logic and thinking are the same. Essentially people make the same mistakes over and over again.

This, in fact, was the original motivation for developing a list of common logical fallacies. We kept encountering the same poor logic time and again and wanted to address the underlying cognitive errors. This is why scientific skepticism is so heavily involved with metacognition – thinking about thinking. There are thousands of fake medical claims out there, for example. Debunking every one is an endless game of whack-a-mole. Better to understand and address the underlying flaw in logic and method that leads to all the medical nonsense.

More recently this phenomenon has been dubbed, “Crank magnetism.” This is the closely related notion that people who believe on type of pseudoscience tend to believe multiple types – they tend to attract each other. The cause of this seems obvious – if your method is flawed, you will achieve the same flawed results over and over.

There may also be different flavors of crank magnetism, although there is a lot of overlap also. For example, there are conspiracy theorists who believe every conspiracy, there are spiritual true-believers who are prone to believing anything mystical, and there are “nature is best” fanatics who are vulnerable to marketing anything as “natural” and fearmongering about “the chemikilz.”

A new ballot initiative in California (of course) is an excellent representation of this latter flavor of sloppy thinking. It combines a reverence for anything natural, an irrational fear of chemicals, and anti-corporate conspiracy thinking into the mother of all crank-magnetism orgies.  According to the state Attorney General:

REGULATES VARIOUS SUBSTANCES AND PRACTICES RELATED TO AGRICULTURE, CONSUMER PRODUCTS, AND HEALTH. INITIATIVE STATUTE. Prohibits genetically engineered plants and animals and over 300 listed substances from being used or released into the environment. Creates new state entity to regulate environmental activities, modify projects having pollution and radiation impacts, and test and approve substances before they can be introduced in California. Prohibits treatment of water with fluoride or chlorine. Regulates vaccine ingredients and eliminates vaccination as a prerequisite for attendance at schools and daycare facilities. Provides criminal and civil liability for violations, with no statute of limitations.

Basically this would put the inmates in charge of the asylum. The proponent of the measure, Cheriel Jensen, hopes to accomplish in one bill the wet dreams of anti-science activists over the last century. She has to collect the signatures of 365,880 registered voters (five percent of the total votes cast for Governor in the November 2014 general election) by August 6th in order to get on the ballot.

The most interesting aspect of the proposed bill is the blatant crank magnetism. It shows the overlap between the anti-vaccine movement, the anti-GMO movement, the anti-fluoridation movement, and the all-purpose toxin fearmongerers. They also throw in the more recent anti-smart meter conspiracy theorists. If it’s new and technological, they are against it.

Obviously not everyone who is anti-GMO is also anti-vaccine. But there is a large overlap. In a recent survey of belief in medical conspiracies, 49% of those surveyed believed in at least one. Meanwhile 18% believed in three or more – it is that 18% that we are talking about here.

There are also cultural reasons for overlap, not just underlying philosophy or cognitive style. People who watch Dr. Oz or other TV doctors were more likely to accept multiple medical conspiracies. This is the “Goop” phenomenon – reverence for the vague concept of “natural,” use of alternative treatments as empowering, and rejection of medical and scientific authority are now a “lifestyle.”

Social media also reinforces crank magnetism. If you watch YouTube videos questioning the safety of vaccines, anti-GMO videos are likely to appear on the right of your screen. The echochamber reinforces the underlying philosophy, not just the specific belief.

This is the power of narrative that I have discussed often here. What psychological research (and personal experience) have revealed is that people need a way to make sense of a complex and often scary world. We need an explanatory narrative. Most of the time we accept the explanatory narratives that are offered up by our culture – we internalize them, embrace them, and then spread them.

One goal of metacognition is to think about these explanatory narratives. Why do we believe them in the first place, what are their strengths and weaknesses, are there any better approaches out there?

So essentially what we are seeing with this ballot initiative is a manifestation of a particular explanatory narrative, one that tries to make sense of the modern technological world as a conspiracy of powerful companies, powerful enough to control or at least heavily influence the government that should be regulating them, who are poisoning the public through careless use of toxins and chemicals. Meanwhile a plucky band of rebels seeks to expose the truth using social media. In this world view, kinder gentler powerful companies are selling the public natural products, food, and cures. Science and scientists cannot be trusted (unless they find what you want to believe and confirm your conspiracies). Anything “chemical” is suspect, and the slightest suggestion that a chemical is harmful can be taken as iron-clad.

Meanwhile, anyone who would challenge this narrative is a troll and a shill working for the powerful companies. You can just assume that to be true, without needing any actual evidence.

If that is your explanatory narrative, then that is the filter through which you see the world, and social media will conveniently cocoon you in an echochamber that reinforces the narrative. Within that world view, it makes sense that vaccines are poison, fluoridation is a conspiracy, GMOs are dangerous, and smart meters are spying on us. If you are willing to dismiss the scientific consensus on one, why not all of them? You have your “alternative” experts giving you alternative facts to support your alternative beliefs.

It will be interesting to see how the ballot initiative does. It is, in a way, a survey on how prevalent this narrative is in California. I suspect the initiative will fail, because it simply goes way too far, and only the 18% hard core believers will go for it. But we will see. Recently history has not been kind to my optimism.

Categories: Skeptic

Significant but Irrelevant – Study on Correcting False Information

Mon, 02/12/2018 - 5:06am

A study from a few months ago is making the rounds due to recent write ups in the media, including Scientific American. The SA titles reads: “Cognitive Ability and Vulnerability to Fake News: Researchers identify a major risk factor for pernicious effects of misinformation.”

The study itself is: ‘Fake news’: Incorrect, but hard to correct. The role of cognitive ability on the impact of false information on social impressions. In the paper the authors conclude:

“The current study shows that the influence of incorrect information cannot simply be undone by pointing out that this information was incorrect, and that the nature of its lingering influence is dependent on an individual’s level of cognitive ability.”

So it is understandable that reporters took that away as the bottom line. In fact, in an interview for another news report on the finding one of the authors is quoted:

“Our study suggests that, for individuals with lower levels of cognitive ability, the influence of fake news cannot simply be undone by pointing out that this news was fake,” De keersmaecker said. “This finding leads to the question, can the impact of fake news can be undone at all, and what would be the best strategy?”

The problem is, I don’t think this is what the study is saying at all. I think this is a great example of confusing statistically significant with clinically significant. It is another manifestation of over-reliance on p-values, and insufficient weight given to effect size.

Here’s the study – the researchers gave subjects a description of a woman. In the control group they asked them to rate her probable qualities, how much they liked her, how trustworthy she was, etc. In the intervention group they also gave the subject false information about her, that she sold drugs and shoplifted in order to support her shopping habit. They also gave a cognitive ability test to all subjects, and divided them into high cognitive ability (one standard deviation above average) and low cognitive ability) one standard deviation below average).

Above is the graph of the results (high definition version here). As you can see, in the control group both high and low cognitive subjects rated the fictitious person as an 82/100 in quality. The intervention group, after give the false negative information, rated her much lower, a 24/26 in the low/high cognitive ability groups respectively. Then, the false negative information was corrected – the subjects were told, never mind, this false information is not true. Now how would you rate the person? The high cognitive ability group then rated her as an 85, while the low cognitive ability group rated her as a 78. The difference between the 85 and the 78 was statistically significant.

I look at this data and what I see is that in both cognitive ability groups, the false information had about the same negative effect, and the correction had about the same corrective effect, and in fact essentially completely erased the effect of the false information. I am not impressed by a tiny but statistically significant effect.

The small effect size has two major implications. The first is that it calls into question the reality of the effect at all. Essentially, the study has a small signal to noise ratio, and this is problematic, especially when dealing with human subjects. It’s just too easy to miss confounding factors, or to inadvertently p-hack your way to a significant result. That probably has something to do with the replication problem in psychological research.

But even if you think the study is rock-solid (and I don’t), and the results are entirely reliable, the effect size is still really small. I don’t know how you can look at this data and conclude that the bottom line message is that people with lower cognitive ability (as defined in this study in a very limited way, but that’s another issue) had difficulty correcting false information. They corrected from a rating of 24 up to 78, with a control group rating of 82. Are you really making a big deal out of the difference between 78 and 82? Is that even detectable in the real world? What does it mean if you think someone’s personal qualities rank 78/100 vs 82/100?

With any kind of subjective evaluation like this, how much of a difference is detectable or meaningful is a very important consideration. I would bet that a difference between 78 and 82 has absolutely no practical implication at all. That means that effectively, even the people in the lower cognitive group, for all practical purposes, corrected the effect of the false information.

I am also not impressed by the difference between the low and high cognitive groups – 78 to 85. That is still not a difference with any likely practical difference. Even this small effect size may be an artifact of the fact that the high cognitive group over-corrected (compared to controls) by a small amount (also insignificant).

And yet the Scientific American headline writer wrote that with this research, “Researchers identify a major risk factor for pernicious effects of misinformation.” “Major” risk factor? I don’t think so. Minor and dubious is more like it. What this research does show is that subjects easily and almost completely corrected for misinformation when pointed out to them.

But even that conclusion is questionable from this data, because the research conditions were so artificial, and the researchers characterize them as ideal. The false information was quickly and unequivocally reversed. This is not always the case in the real world.

Unfortunately I see this phenomenon a lot. Social psychology studies take a tiny but statistically significant outcome, and then over-interpret the results as if it is a large and important factor. Then journalists report the tiny effect as if it is the bottom line result, leaving the public with a false impression, often the opposite of what the study actually shows.

We see this in medicine all the time also. This is the frequentist fallacy – if you can get that p-value down to 0.05, then the effect is both real and important. However, often times a statistically significant result is clinically insignificant. Further, small effect sizes are much more likely to be spurious – an illusion of noisy data or less than pristinely rigorous research methods.

This is why some journals are shifting their emphasis from p-values to other measures of outcome, like effect sizes. You have to look at the data thoroughly, not just the statistical significance.

Further, researchers have to be careful not to oversell their results, and science journalists need to put research results into a proper context.

 

Categories: Skeptic

Ontario College Plans Program in Homeopathy

Fri, 02/09/2018 - 5:15am

Here we go again.

If you are in a decision-making position at an institution of higher learning than you have a responsibility to understand and protect the academic reputation of that institution. Further, such institutions (many of which, as in this case, are publicly funded) have a responsibility to society, to promote academic standards and legitimacy. At the very least such institutions should not be promoting pseudoscience, or dressing up any nonsense as if it were real.

Georgian College in Ontario has approved funds and plans to open a program that will teach homeopathy as if it is real medicine. Teaching any pseudoscience is an outrage, but when it is medical pseudoscience there is also arguably another layer of malfeasance because the connection to real harm is more direct.

I know this is old territory here, but for review: Homeopathy is a prescientific philosophy-based system based on magical thinking. Its core ideas were never valid, and have never been supported by science. Essentially, homeopathy uses fanciful treatments that are based on silly ideas, such as the personality of the patient, but also “sympathetic magic.” The belief is that homeopathic remedies contain the magical essence of symptoms and can be used to cure those same symptoms.

Then, doubling down on the idea of magical essence, all actual substances are diluted out of existence, so that only the essence remains. Therefore, in reality, only water remains. Homeopathy is literally treating people with magic water created with rituals resembling witchcraft, but without the tiniest bit of scientific legitimacy.

Despite this, a great deal of resources have been wasted studying whether such magic potions work or not. Unsurprisingly, the totality of this research shows that homeopathy does not work.

Homeopathy proponents, however, will not acknowledge this reality. They cherry pick, distort, lie, ignore, and engage in an impressive array of motivated reasoning to maintain their belief in magical potions. I have no idea where any individual homeopathy seller is on the spectrum from con-artist to true-believer, but it doesn’t really matter. They represent some combination of not caring about scientific evidence, or not being able to understand the evidence.

There is no real controversy here. This is the clear scientific consensus, and is unambiguously supported by the science.

So, how could an academic institution consider teaching a degree program in pure nonsense? That’s a good question. Let’s here from Fay Lim-Lambie, dean of health, wellness and science at Georgian College.

“As an educational institution we welcome critical discussion and debate,” she said. “It helps ensure the best possible curriculum and learning outcomes for our students.”

She added that, “In an era of patient choice, it is important for the college to provide students with the most diverse education possible, including options for care and different methods.”

I’m sorry, the dean of what? Was that health and science? I hear there is returning interest in astrology. Perhaps the astronomy department (if they have one) should consider teaching astrology in order to cater to this interest, to give their students a diverse education. Let’s have a critical discussion and debate about that. Seriously – if you think a program in homeopathy is appropriate at your institution, then you have absolutely no basis on which to deny programs in cryptozoology, creationism, crystal healing, UFOlogy, or free energy. You have abandoned all pretense to academic standards.

This is a transparent populist appeal which is anti-intellectual and pseudoscientific. This is, and should be, an embarrassment to Georgian College, Ontario, and to academia in general. The only appropriate response is outrage and condemnation.

There is nothing to debate, Lim-Lambie. Homeopathy is utter nonsense from beginning to end. If you don’t understand that thoroughly, you have no business being a dean of either health, wellness, or science. And why wasn’t this desired debate happening before the funds were approved for this dubious program? Does she only want to have a “debate” now that there is public awareness of what is happening with the resultant appropriate criticism and pushback?

Yes, I am being hyperbolic in this article, deliberately. The point is that legitimizing pseudoscience in the health department of a university is extremely harmful. It promotes pseudoscience, it legitimized nonsense, and it undermines any attempt at academic quality control.

It furthers the watering down of reality in our society by promoting a false equivalency among all claims. Everyone gets to have their own reality, their own narrative, their own facts and evidence. If there is no difference between academic legitimacy and the worst kind of medical magic thinking, then we truly do live in a post-fact world.

I know that most of us have already spent our budget of outrage, but we cannot become inured to this loss of standards, to the infiltration of witchcraft into medicine. I am not a fan of public shaming, but sometimes that is the only way to maintain norms and standards. Georgian College and Lim-Lambie should be ashamed. They have failed their primary duty as academics.

But I also believe in nurturing and redemption. Let’s use this opportunity to have a public and transparent discussion of exactly what homeopathy is, and what the evidence says. Homeopathy proponents like flying under the radar, and the public largely does not understand what homeopathy actually is. So let’s put it out there. If Lim-Lambie wants to defend homeopathy “science” then she should do it – publicly. Please, proceed.

Categories: Skeptic

Did a Comet Kill the Mammoths

Thu, 02/08/2018 - 6:38am

Between 12,800 to 11,500 bp (before present) there was a cold period in North America called the Younger Dryas – named after the dryas flower whose pollen is a good marker for such cold periods. During this time the megafauna of North America, including the Mammoth, largely died out. Along with them went the Clovis culture – a big game hunting culture with distinctive stone points.

What caused this period of climate change and mass extinction?

This is a genuine scientific controversy. One group of scientists believe that the melting glaciers dumped fresh water into the northern Atlantic, temporarily shutting down the ocean currents that bring warm water to North America. Another group think that a comet impact is to blame.

There is no smoking gun of a comet or meteor impact at this time, however. This is partly why the debate continues. However, there is significant inferential evidence, and as this evidence grows we may be getting to a tipping point where the comet theory becomes dominant.

There are two new published papers which the authors claim support the comet theory. I don’t know if this will be the tipping point, but the evidence is starting to seem pretty compelling. We’ll have to see how the other side reacts.

The Big Burn

So far the evidence presented for a comet impact is indirect but some scientists find it compelling. Mostly it consists of finding exotic materials in the geological layer that corresponds to the Younger Dryas boundary.

These exotic materials include spherules, nanodiamonds, melt glass, and a platinum spike. Comet impact proponents argue that these materials resulted from the impact. Critics claim that they are either erroneous or result from other causes, such as forest fires. And in any case – without an impact crater, the case for an impact is thin. Meanwhile the case for glacier melt is strong.

Now the comet proponents are firing another salvo – evidence from ice cores and other studies showing that right at the Younger Dryas boundary layer there is evidence for massive biomass burning. Further, there is a CO2 spike at the same time, enough to suggest that as much as 10% of the plant life on Earth at the time burned.

What this could mean is that there wasn’t a single impact, but that essentially the Earth passed through the cloud of a comet and was hit by a swarm of smaller pieces, igniting forest fires around the world.  Smoke from these fires could have then resulted in an impact winter – blocking out the sun reducing photosynthesis and reducing temperatures.

This conveniently explains away the absence of a large impact crater, while also explaining the presence of exotic impact-related materials, and also the products of massing burning, all at the Younger Dryas boundary layer.

This sounds like a reasonable case for the comet theory. Will it be compelling enough, however, to win over former critics?

Scientific Controversies

That is often how these scientific controversies work. Different factions make their case in the absence of definitive evidence, and also point to future evidence that will support or refute their hypothesis. The various sides duke it out, until eventually the evidence builds enough on one side that the majority of scientists come over.

There is no magic threshold, but at some fuzzy point we may have a consensus built on evidence that has been thoroughly debates by proponents of various hypotheses. A consensus does not mean 100%, no further evidence needed, the science is over. It just means that the evidence is strong enough in support of one side that the vast majority of scientists now accept that as the most likely answer.

There is always room for minority opinions, and sometimes surprising lines of evidence may disrupt the debate.

We see this process with many current scientific controversies. Is floresiensis (the Hobbit) a unique species or a diseased human? Did the dinosaur extinction result entirely from an impact, or did other sources of climate change play a role?

For a time there was serious debate about whether or not dark matter existed or were observations explainable by modifying Newtownian gravity. We have now reached a consensus that some form of dark matter probably exists – but until we identify exactly what it is, there is room for dissent.

There are countless such debates, big and small, in the world of science. That is how science works and progresses. For every question, there is a spectrum from unknown, to genuine controversy, to strong consensus, to rock solid. Science communicators should always strive to put any new study or bit of evidence into the context of where the scientific question is on this spectrum.

Further, there are practical implications for properly characterizing the state of a scientific controversy. What do we teach in classrooms? What research do we fund? Was medical treatments are acceptable, and should be reimburse with public funds? And what scientific conclusions are sufficient to base public policy on?

There is no formula. This takes judgment, a thorough understanding of the science, and an individual decision. Conclusions also have to remain open to revision as new evidence and theories come to light, but we also have to make decisions in the meantime.

The obvious controversy to which all this applies is global warming, because it is such a hot political topic. The prevailing scientific opinion is that there is a strong-enough consensus that global warming is happening and is due to human activity to form a basis for policy. That does not mean the science is over, and there are always error bars on every scientific conclusion. But we have a practical consensus. It would be folly to ignore it, or to focus myopically on uncertainty in order to manufacture paralysis.

It is useful to examine non-political scientific debates and controversies, to see how they work, and how they are resolved. Not many people are going to have a strong ideological position on the Younger Dryas, and I don’t expect to see it in the platforms of major political parties. That is why it is a great way to see how science works. Those lessons can then be applied to more politically controversial topics.

 

Categories: Skeptic

Mindfulness No Better Than Watching TV

Tue, 02/06/2018 - 5:14am

A recent systematic review and meta-analysis of the effects of mindfulness meditation on prosocial behavior found, essentially, that there is no evidence that it works. I find these results entirely unsurprising, and they yet again highlight the need for rigorous research before concluding that a phenomenon is real.

As I discussed recently on SBM, mindfulness meditation is the practice of sitting quietly, focusing inward and on the present, and avoiding mind wandering or daydreaming. The recent review I discussed on SBM found that the research into mindfulness, however, does not use a uniform or operationalized definition. That is critical to good science – you need to carefully define something before you can do research on it.

It is especially important to specifically define a concept in order to do research into the question of whether or not the phenomenon is real. If your question is, “Does X exist,” you better have a very specific definition of what X is. Otherwise it is easy to misinterpret the evidence, or to wiggle out of evidence that X does not exist.

The best example of this in medicine is acupuncture. Acupuncture is defined as sticking thin needles into acupuncture points – except when research shows that it does not matter where or even if you stick the needles, then acupuncture can be something else, which is vaguely defined.

Once you have a specific definition, with clearly identified variables, then you can study if those variables which constitute the phenomenon in question have a specific effect. For mindfulness – what is the effect of relaxation, introspection, or avoiding daydreaming? Does mindfulness differ from other methods of achieving these same effects? Perhaps mindfulness is nothing more than relaxation, or perhaps any perceived effect comes from being distracted for a time from the stresses of your life.

In other words, mindfulness may not be a real distinct thing, but just one method of achieving other more fundamental states, such as relaxation. This is what appears to be the case, based on years of research, in which case proponents should claim, “Mindfulness is an effective method of relaxation, which can have benefits,” not “Mindfulness is a unique phenomenon with specific and unique benefits.”

Does this matter? Absolutely. It is almost guaranteed that when I post an article such as this someone will say, “Who cares, as long as it works.” But this is an unscientific attitude. In science, the details do matter. We need to know what is really real, because it affects how we implement interventions and how further scientific research proceeds.

Using acupuncture as an example again – if the sticking of the needles adds no specific effect or value, and all the benefit derives from the interaction with the acupuncturists (which is what the research clearly shows), then we can dispense with the needles. The needles are invasive and come with risk. Further, we don’t need to speculate about the mechanism of benefit from sticking people with needles, because there is no mechanism. We can shift our focus to the real phenomenon – a subjective effect from a positive therapeutic interaction.

With mindfulness, because there is nothing invasive, the situation is the same, if less obvious. If, as the recent review shows, watching nature documentaries are as effective as mindfulness, then you can simply turn on the TV, learn something about nature, and get all the apparent benefit of meditation. You also don’t have to spend hundreds of dollars on that mindfulness course. We can further stop wasting our time researching a scientific dead end.

Let’s get back to the recent review to see those details. What the researchers found when they reviewed the literature on prosocial behavior is that the research did not establish that mindfulness had any specific benefit. First, we need to define prosocial behavior more specifically. The authors write:

Five types of social behaviours were identified: compassion, empathy, aggression, connectedness and prejudice. Although we found a moderate increase in prosociality following meditation, further analysis indicated that this effect was qualified by two factors: type of prosociality and methodological quality. Meditation interventions had an effect on compassion and empathy, but not on aggression, connectedness or prejudice.

That’s important to know for research, but not really the most interesting finding of the research. They also found:

We further found that compassion levels only increased under two conditions: when the teacher in the meditation intervention was a co-author in the published study; and when the study employed a passive (waiting list) control group but not an active one.

So studies were only moderately positive when one of the study authors were teaching the subjects meditation. This suggests that researcher bias is at work.

Perhaps more importantly, however, is the fact that there was only a measured effect when there was a waiting list control, meaning there is an unblinded comparison where the subjects had no intervention. When the control was “active”, meaning the control group had some intervention, then there was no effect. This intervention could simply be watching a nature documentary. This one fact alone means the research is negative. Everything else is interesting, but doesn’t really matter.

The meta-lesson here is that this kind of analysis of the entire literature on a specific scientific question is necessary before you can come to any reliable conclusion about efficacy. If you want to know if an alleged phenomenon is real, you need rigorous research in which variables are clearly defined and adequately controlled for. Further, you need positive results with a clinically significant (adequate signal to noise ratio), statistically significant, and independently replicated effect.  Until you get to that threshold, you are likely just dealing with researcher bias, p-hacking, publication bias, and loose methodology creating the illusion of a positive effect.

With some alleged phenomena, however, we never get to the threshold of acceptance. The research just goes around in circles chasing its tale. This is true of acupuncture research, mindfulness meditation, ESP, homeopathy, and essentially all the familiar pseudosciences. All we get are excuses, hyping of preliminary research, cherry picking positive studies, and personal attacks against skeptics who would dare to question the alleged phenomenon. In medicine we also get the, “Who cares, as long as it works.” This, of course, misses the point that the alleged treatment doesn’t really work, it is all an illusion.

Another defensive response is to claim, “Well, that is not the real claims being made for X. It’s really about this other thing over here.” This kind of response, however, is usually just part of a dance of avoidance. “They didn’t study real astrology.” “That is not the real reason to fear GMOs.”

But this approach, which often is just motivated reasoning, further misses the point that the person making the claim has the burden of proof. It’s not on me to prove with high quality research that mindfulness doesn’t work for every possible claim made for it. Proponents have to adequately demonstrate that it does work for a specific claim, and they haven’t. Scientists will then conclude, “The research does not justify rejecting the null hypothesis.” This is technically true, as is appropriate in scientific discourse. When communicating to the public, however, it makes it seem like we don’t really know the answer.

At some point (and where this point is admittedly requires judgement, which includes an evaluation of plausibility) a lack of evidence can be treated as, “OK, this probably doesn’t work.” At the very least, we can conclude that this is a scientific dead end.

There is also an asymmetry in the media. A systematic review like this, concluding that the evidence is inadequate to support a conclusion that mindfulness is effective in promoting prosocial behavior, just doesn’t get that much play. However, a crappy preliminary study with poor methodology and brimming with bias and p-hacking, which shows an apparent tiny effect, will be promoted in the media as proving that mindfulness works magic. Rarely will such studies be put into the context of the entire literature.

Media and marketing forces tend to lead to an adoption of new ideas long before they are adequately demonstrated. Then once they are embedded in the culture and the popular consciousness, they are hard to eradicate. The public ends up believing a lot of stuff that is simply not true. Then when skeptics or scientists point out that the research was never adequate to conclude the phenomenon is real, and now after 20 years or so we can more clearly say it probably isn’t, they seem out of touch. Everyone already knows that antioxidants are great for you, never mind that the research shows they have no benefit.

We can now probably add mindfulness to the list. I was never impressed with the research, and the claims always seemed poorly defined. Now, we have multiple systematic reviews which show essentially that. We may not be at the point where the concept can be completely abandoned, but we are at least getting close. The most parsimonious interpretation of the science at this point is that mindfulness is just a ritualized form of relaxation, with no specific benefit beyond that. If you enjoy it and find it useful, fine. If you prefer watching Blue Earth II, then I’m with you. Just don’t spend hundreds of dollars on courses, tapes, or seminars because you bought the hype.

Categories: Skeptic

Neuro-Quantum Entanglement Pseudoscience

Mon, 02/05/2018 - 5:06am

On the Canadian Entrepreneur show, Dragon’s Den, the dragons were given a demonstration of a clip (that’s right, a small metal clip like you would use to hold papers together or put in your hair) that the creator claimed would improve your balance, strength, and health through the power of “quantum entanglement.” The clips, called Neuro Connect, were “developed” by a chiropractor and his partner. The Dragons fell for it, amazed by the demonstrations, and invested $100,000 for a 30% share.

The show aired, giving a huge boost to the company’s sales. However, the way the show works, even when the Dragons make a deal on camera, the deal is contingent on them doing due diligence for confirmation. When they did they found that there were serious scientific objections to the claims being made by company selling the clips, NeuroReset Inc. The deal was off.

But this did not stop the show from airing. The public did not get the benefit of their due diligence – they protected themselves, but completely threw their audience under the snake oil bus.  Canadian news outlet CBC contacted the producer to get their response:

Executive producer Tracie Tighe was asked what responsibility the show has to protect consumers from products that make false or outlandish claims.

“The entertainment value of this first meeting is what appeals to our viewers and is the pillar of success for this reality format,” she said in an email. “The pitchers sign extensive releases/agreements and they are required to confirm their business proposals comply with all applicable legislation.”

Typical – in other words, we don’t care if we are deceiving our audience. We hold ourselves to no responsibility. We will air the Dragons fawning over a product we now know is bogus and where they backed out of the deal without giving our audience this information, because it is entertaining (i.e, it makes us money). So the producers of Dragon’s Den are snake oil salesman also.

The Neuro Connect clip itself is just a recycled scam. This is the Q-bracelet, the power band, the Goop stickers all over again. The formula is now well established. Take any small cheap piece of plastic, rubber, or metal. Give it an exotic name or one that implies a claim or a mechanism. Then claim that by wearing the doodad you will have more energy, better balance, improved strength, or that great catch-all term, “wellness.”

How does this miracle little thingamabob work? Science, or something. Energy, bla bla, vibrations, bla bla, magnetic quantum phase inverters bullshit, bla bla.

That is really it. Anyone can be the next energy doodad entrepreneur. Just find a factory in China that can make small plastic widgets really cheap and print your custom log on it, and that make up some formulaic BS about energy, and that is apparently enough to fool (at least for a while) allegedly expert investors.

To really sell it all you need is knowledge of a few simple parlor tricks. Here is NeuroReset demonstrating the parlor trick to sell their snake oil. Here is Richard Saunders in 2012 exposing the same exact parlor trick.

There are a few similar parlor tricks that have done a lot of heavy lifting helping snake oil salesman make their sale. The one in the videos is an old “applied kinesiology” trick that has been used in many contexts. You have the mark hold up their arms to the side. Then you push on the arm so show how weak they are. Give them the quantum entanglement whatever, and then when you push they are stronger – you can’t break them. However, small changes in where and how you push make all the difference.

There are other tricks where you have people rotate to see how flexible they are – they always rotate a bit further on the second try, and when they have a target to beat (when they are using the magical device).

And of course this is a great example of using the latest scientific knowledge to dazzle a scientifically illiterate audience. There is simply no way that a Canadian chiropractor has unlocked the potential of quantum entanglement. It’s a fair bet he does not even understand what quantum entanglement really is, or how we experimentally know it exists. He has no explanation for what is actually happening, or how he managed to exploit quantum entanglement in a little metal clip (I’m sure the physicists of the world are fascinated).

And when confronted with this he gives the same answer that most snake oil peddlers give:

“Can you criticize me for no peer reviewed studies? Absolutely,” he said. “We’re helping too many people, which is why I’m standing up for it.”

That right – I am too busy curing people to bother with conducting rigorous studies. This is a giant red flag for a scam.

Regulatory agencies are trying to do their job:

In an email, Health Canada said it’s investigating potential additional claims for two other Neuro Connect products. The agency said appropriate action will be taken if it finds compliance issues.

Sure, but this is just a game of whack-a-mole. There is an asymmetry here in which it is far too easy to mass produce these snake oil scams, which then takes far too much time and resources for a government agency to investigate. By the time they do, the company has made their money and moved onto the next scam.

Categories: Skeptic

Carbon Capture

Fri, 02/02/2018 - 5:15am

Hopefully it’s not news to you that the Earth is warming due to human release of carbon dioxide and other greenhouse gases. A number of studies have assessed the scientific consensus on anthropogenic global warming (AGW), with results clustering around 97%. Overwhelmingly, most climate scientists have looked at the data and concluded that AGW is happening.

Climate scientists have gone beyond just establishing that AGW is happening. They are trying to quantify it and project the trend lines into the future. This type of effort is always fraught with uncertainty, with the error bars increasing with greater time into the future. However, we can take a 95% confidence interval and make reasonable extrapolations of what is likely to happen.

Recognizing this uncertainty, the Intergovernmental Panel on Climate Change (IPCC) has concluded that we should keep post-industrial warming to less than two degrees Celcius if we want to avoid serious effects of climate change. Given that as the goal, they can then determine how much more carbon would need to be released to cause this amount of warming. This can be used to determine how much we need to decrease future carbon emissions.

Primarily those with an ideological or financial stake in denying this solid consensus focus on the uncertainty. But that is folly. Phil Plait has a good analogy – if 97% of the world’s astronomers were in agreement that there was a 95% chance of an asteroid hitting the Earth in 2050, would you be listening to the 3% of dissenters? If NASA and other experts were mostly saying that it will take 20 years to develop the technology to deflect the asteroid, and the earlier we do it the more effective our attempts will be, do you think it would be prudent to argue for waiting a couple of decades to see what happens? Maybe the asteroid is not as big as they say. Maybe it will hit in a remote area and not do that much damage. It may cost less to fix the damage than divert the asteroid. Asteroids deliver useful metals to the Earth’s surface, so this could be a good thing. Don’t listen to the asteroid hysterics. The motivated reasoning is transparent.

Denial aside, we are now getting to the point that simple math is constraining our options. We have to reduce our carbon release quickly in order to avoid the 2 degree C warming. We can argue about how quickly, but we are actually just arguing about how long it will take for the worst outcomes to be manifest. It is not a question of if, but of when. We can hope for the best outcome, but should plan on the 95% confidence interval.

Those same scientists, however, are saying essentially that it is highly unlikely we will be able to reduce CO2 emissions quickly enough. We will certainly not do it if current trends continue – the math just does not work. Still we need to do everything we can – increase energy efficiency, shift to renewable energy, and reduce fossil fuel use.

Another option is carbon capture – remove carbon from the atmosphere to offset the new carbon being released. Here the IPCC has a dilemma. They have charted all possible pathways to avoid the 2 degrees warming, and they have concluded that essentially we cannot do it through reduction of emissions alone. In the second half of the 21st century we will need to remove a significant amount of carbon from the atmosphere, about 12 billion tons per year, or a third of the current rate of release.

However by focusing on carbon capture they worry that people will see such technologies as the ultimate solution, and therefore we don’t have to worry about reducing carbon release. So now they are also emphasizing that carbon capture will not be enough. We need to do both – reduce emissions and carbon capture.

This is where another layer of thinking comes in – techno-optimism. There are those who argue that we will technology our way out of this dilemma. Renewable energy technology will advance and replace dirty old energy technology. We will also develop high-tech carbon capture technology and take care of all that extra carbon. I am sympathetic toward this attitude, but I also agree that we cannot rely on technological advances we haven’t made yet. These are always hard to predict. Again – hope for the best, but prepare for the worst. We can’t just assume that in 30 years we will develop a technology to deflect the asteroid.

But what is the state of carbon capture? One approach is essentially to use plants, specifically trees. Trees are natural carbon capture devices. There are already efforts ad reforestation, and to reduce deforestation, and they should continue. But this will not really address the problem. There isn’t enough land to simply plant trees to capture carbon, and trying to use lots of land for this approach will likely be counterproductive.

There is on company, Climeworks, that uses artificial filters to capture carbon. They have one factory that currently captures 1000 tons of carbon per year. If you remember from above, we would need about 12 million of these to reach our goal. That is why the IPCC is now saying we cannot rely on this technology alone. How much space would all that carbon capture require?

The company calculated how many shipping container-sized units would be needed to capture 1% of global emissions; the answer was 750,000.

So again, multiply that by about 30 for what we would need.

The technology works by using fans to blow air over filters which capture carbon dioxide. When the filters are full they can be heated to release the carbon in solid form. That solid carbon can be buried or used for industrial use – you can combine it with hydrogen to make plastics or fuel, for example.

It seems that some such technology will be necessary to reach our goal of limiting warming to 2 degrees C. This technology at least works, but it is primitive. It seems prudent to encourage development of this technology. One way to do that is to put a price on carbon. I agree with those who argue that this makes sense and is fair, since releasing carbon has a cost to the world, those who release the carbon should share in that cost. They could, however, offset that cost by also building carbon capture facilities, or buying carbon credits from those who do.

Make a carbon capture industry cost effective, and it is likely the technology will advance an be adopted. Then we might technology our way out of this.

While I remain hopeful, maybe even optimistic, I realize that the math currently looks bad. We cannot get complacent. Now really is the time to shift to renewable energy, to focus on energy efficiency, and to put a proper and fair price on carbon to encourage a carbon capture industry. This is a win win – we will end up with a better energy infrastructure, and a better environment.

Categories: Skeptic

A Case of Brain Death

Thu, 02/01/2018 - 5:19am

The New Yorker magazine’s latest issue features an article about the sad story of Jahi McMath. Jahi was a 13 year old girl who four years ago underwent a routine tonsillectomy to treat severe snoring and breathing problems. Unfortunately the surgery was complicated by severe bleeding post-op, leading eventually to a cardiac arrest. After a sustained effort at resuscitation the doctors did manage to get her heart working, but by that time her brain was severely damaged by lack of oxygen. She was declared clinically brain dead.

This is not where the story ends, however. Since then the family has refused to accept the diagnosis of brain death, prompting a prolonged conflict with the hospital. Eventually Jahi was removed by the family to an undisclosed hospital in New Jersey, and ultimately discharged to home care, where she remains.

I have had several questions about the story, and I will try to add some insight, with the caveat that I have no direct knowledge of the medical facts of the case beyond what is reported in the New Yorker article and elsewhere. I have not examined her, spoken directly to anyone involved in her care, or reviewed medical records. But there is a lot of information in the public domain and I can speak to that information, as far as it is accurate.

There are several layers to this story. There is a legal layer, as the family is suing the hospital for malpractice. I will not address that aspect of the case. There is the neurological layer – what is brain death and is this girl dead? There is also a personal and cultural layer here in terms of the family’s reaction. Let me start with some thoughts on this.

I will first say that I completely sympathize with the family. Of course it is horrible and tragic to lose a healthy 13 year-old child to a routine surgical procedure gone horribly wrong. I understand their anger, frustration, and grief. In addition, the family (again, according to public reporting) has lost trust in the hospital and in the system. They are African American and feel that there is an aspect of discrimination in how Jahi was treated. The mother, Nailah, is quoted in the New Yorker article:

Nailah, who worked in contractor sales at Home Depot, said, “No one was listening to us, and I can’t prove it, but I really feel in my heart: if Jahi was a little white girl, I feel we would have gotten a little more help and attention.”

This is an extra layer of tragedy in the case – the family was meant to feel as if an element of racism played a part in Jahi’s outcome. I have encountered this myself numerous times, sometimes with some legitimacy, but often (from my perspective) when no racism was present. I can’t speak to the state of mind of any of the caregivers in Jahi’s case. But the reality is that her family lived with enough racism in society that it affected their ability to trust the system.

Allowing your child to go under the knife requires a tremendous amount of trust. Further, medical care can often feel impersonal, and can be intimidating when scary things are happening that you do not fully understand because you are not an expert yourself. When that trust, and that feeling of lack of control, is paired with a horrible outcome, it is natural to feel betrayed.

Those feelings, in the context of a minority family, appears to be driving this case to a significant degree. Now those same doctors are telling the family that Jahi, who looks alive, is actually dead. They don’t want to let Jahi down again by trusting those same doctors.

Unfortunately, when there is a critical break down of trust like this in a complex case, we don’t really have a good mechanism for resolving any conflict. Doctors and hospitals usually defer to the family as much as possible, giving them time to process their grief, having family meetings, calling in other experts to weigh in, etc. None of this was enough, however. It also seems that the family has dug in their heels, and may now be too invested in their belief that Jahi is alive to let her go.

This leads us back to the neurological layer of this story. The New Yorker article framed their piece as a question – what is the definition of life. There is a legitimate question in there, but I don’t think it is actually that controversial outside of certain religious sects.

Obviously, when someone stops breathing and their heart irreversibly stops beating they can be declared dead. For a time, however, the cells in their body are not dead. There is a window when someone may be dead, but it is not necessarily impossible to resuscitate them. Doctors use their judgement when deciding to stop attempts at resuscitation. Part of that judgement is how much brain damage may have resulted from the prolonged arrest. There is no point in getting a heart beating again if the brain is dead or almost dead.

For this reason the medical and legal concept of brain death was developed. You can also declare someone dead even if their heart is beating if a thorough examination clearly indicates that there is zero brain function. Not only the higher parts of the brain, but the brain stem and the brain reflexes must also have no function. You can still have spinal cord reflexes, however, and still be considered brain dead. You can also demonstrate the complete absence of brain wave activity, or the complete absence of blood flow to the brain.

In Jahi’s case, a neurological exam specifically designed to test for any flicker of brain activity was consistent with brain death. Further, a blood flow scan showed no blood flow to the brain. She was declared brain dead, and is legally a corpse (to be blunt). That is why the family moved her to New Jersey, which is one of only two states that recognize religious objections to the notion of brain death.

This is where we now get some complexity, although I honestly don’t think it changes the situation. Dr. Alan Shewmon got involved with the case – he is a neurologist who objects of ideological and religious grounds to the notion of brain death. He reviewed video of Jahi and concluded there is evidence in the video of brain activity, therefore she is not dead.

Essentially, Jahi occasionally twitches her fingers or toes. These are almost certainly spinal reflexes, and not inconsistent with brain death. Nailah, her mother, believes that Jahi is responding to verbal commands. She will tell her to move a finger, and then sometime later Jahi will move a finger. If it’s not the right finger Nailah will say, “Not that one” until she twitches the correct finger.

This is also very common – family members tend to overinterpret random movements as if they are deliberate. Shewmon believes that the movements are more accurate than can be explained by random chance, but I am doubtful. Further, he may not be accounting for selection bias in the videos he is being shown.

There is good reason to believe that Jahi simply cannot be following verbal commands. The New Yorker reports:

On the scans, Machado observed that Jahi’s brain stem was nearly destroyed. The nerve fibres that connect the brain’s right and left hemispheres were barely recognizable. But large areas of her cerebrum, which mediates consciousness, language, and voluntary movements, were structurally intact.

There are two things to note here. This study apparently does show some remnant of brain tissue. If there were zero blood flow the brain would be entirely gone by now. So there is likely a small amount of residual blood flow, too little to show up on the prior scan, that is keeping some brain tissue alive. However, that does not mean that this remnant is functioning at all.

But perhaps more important is the fact that the brain stem is “nearly destroyed.” The brain stem is necessary for a person to be conscious. Even if your entire cortex were intact and unharmed, without a brain stem you would be in a permanent coma, without the ability to generate wakeful consciousness.

Further, without a brain stem there is no way for auditory signals to get to the brain. Jahi cannot hear, and therefore cannot respond to verbal commands. Therefore the video evidence of her finger twitching is not evidence of consciousness.

There is perhaps a legitimate discussion to be had about whether or not the remnants of brain tissue mean Jahi is truly completely brain dead or not. But in my opinion, this is a distinction without a difference. She is clinically brain dead, and any remnant is irrelevant. She is not aware of her own existence. Without a brain stem she cannot be conscious. It is sad to say, but there is no functional difference from Jahi’s perspective between being fully dead and whatever flicker of brain activity may plausibly remain. It is effectively nothing.

The family may be beyond the trust necessary to accept this reality. They also appear to be enabled in their denial by Shewmon, who has an agenda of his own.

Meanwhile millions of health care dollars have been spent maintaining this poor dead girl’s body, with no end in sight. The family remains in a limbo of denial. The other child in the family must live in the shadow of their dead sister, who absorbs much of the family’s time and resources. Legal expenses are also piling up. The entire saga furthers a narrative of distrust. It is a tragedy from beginning to end.

Categories: Skeptic

Gattaca

Tue, 01/30/2018 - 5:16am

The Human Genome Project was started in 1990 and completed in 2003. It took 13 years, multiple labs around the world, and hundreds of millions of dollars to sequence the human genome – this was more than two years ahead of schedule and millions of dollars under budget.

The reason for exceeding expectations is that the technology for sequence the genome was not static – it progressed throughout the project. DNA contains a code of four letters, the nucleotides indicated by the letters G, T, A, and C. This four-letter alphabet creates 64 different three-letter words, which code for different amino acids or operations that control the conversion of the code into proteins. Sequencing the genome essentially consists of discovering the order of these four letters in the string of a DNA molecule.

In 1997 the movie Gattaca, right in the middle of the genome project, portrayed the near future in which a cheek swab would rapidly yield an individual’s genome. It turns out this is not far fetched at all – we are almost living in Gattaca’s near future, at least in terms of sequencing technology. Scientists have just published a report of the nanopore device, which is a hand-held device capable of sequencing an individual’s genome.

This represents one of the greatest technological advancements in our time – the improvement by orders of magnitude the ability to cheaply and quickly read an entire human genome. The company who makes the device, Oxford Nanopore, claims that the small handheld sequencer, the MinION, can sequence 10-20 Gb per 48 hours (a Gb is a gigabasepair, or billion letters in the genome). In the published study the MinION was used to sequence 91.2 Gb of data to complete the sequence:

The final assembled genome was 2,867 million bases in size, covering 85.8% of the reference. Assembly accuracy, after incorporating complementary short-read sequencing data, exceeded 99.8%.

The device costs $1000. So in a couple decades sequencing a genome went from hundreds of millions of dollars to 1000 dollars, that’s at least five orders of magnitude. Sequencing has also gone from 13 years to a few days (shorter if a larger version of the nanopore is used). They also make the SmidgION, which is even smaller and attaches to a smart phone.

The advantages for research are obvious. With rapid and cheap sequencing technology we can sequence the genomes of many plants and animals. This allows us to study evolutionary relationships, to identify new species, and to “barcode” plant species. Medical applications are also obvious – we can identify genetic diseases in individuals, and researchers can more easily locate specific genes that cause or predispose to certain diseases. There are now over 2,000 tests available for human genetic diseases.

There are also some applications which may not be immediately obvious. For example, researchers can track the spread of an infectious disease more easily if they can trace how strains mutate as they spread. This was done to track the latest ebola outbreak, for example.

The Human Genome Project, in addition to being an example of extremely rapidly progressing technology, is also an example of overhype. It was often overpromised in popular coverage of the project that once we sequenced the genome, there would rapidly be numerous medical applications.  Diseases would start falling one by one. Fifteen years later, this hype has not been realized, although it is starting to be. This is partly because being able to sequence the genome is only one piece to the puzzle. We also have to know what all those genes we are sequencing do.

This has led to the proteome project – the effort to map which proteins all those genes code for. We also have to know what the proteins do, how they are regulated, and what goes wrong in specific diseases.

What the genome project has done, however, is made all this later research faster and cheaper. But still, this kind of research takes years and decades. What often happens is that scientific and technological advances are met with unrealistic hype. However, wait 20 years and the hype eventually becomes a reality (sometimes – I’m still waiting for my flying car). We may be getting close to that situation with the human genome, especially now that CRISPR has given us the technology to rapidly and cheaply alter that genome.

What about the abuses of this technology that was the focus of the movie Gattaca? In the film rapid sequencing was used to identify those who were genetically fit (valids) and separate them from the unfit (invalids). This created a social caste system based on genetics. The situation was also tied to the idea of guided vs unguided conception – having children and just throwing the genetic dice, or guiding conception by choosing the best genes for your children.

While I don’t think it will play out as in the movie, these ideas are not far fetched. Superior genes will likely become one more bit of social and biological capital that the wealthy will be able to transfer to their children. The ability to remove genetic diseases, and even reduce genetic predisposition to disease, is overall a good thing. This technology can lead to a healthier population, and perhaps even reduce health care costs by eliminating expensive lifelong illness. It may even be cost effective for society to pay for such genetic treatments for everyone, rather than assume the health care costs of the otherwise avoided illness.

There are too many variables to predict how this will play out, but it is not too early to start thinking about possible applications of this technology and how it should be regulated. Like many of our advanced technologies, it can be a great thing, but it can also be abused or lead to unintended consequences. The rate at which such technologies are advancing is also both a boon and a challenge. It doesn’t give us much time to adapt to the advancements.

Categories: Skeptic

Shameless Organic Fearmongering

Mon, 01/29/2018 - 4:58am

I and others have long pointed out that anti-GMO fearmongering was largely created by the organic food lobby as a way of smearing their competitors. The strategy is simple – scare people way from genetically modified organisms (GMOs) and offer organic products as a non-GMO alternative. This is nothing new in advertising, create a fear and then offer your product as a safe haven.

A recent video posted by Stonyfield Organic makes the connection between anti-GMO fearmongering and buying organic explicit, as the screen capture shows.

There are many problems with this short video, not the least of which is that they use young girls to parrot their anti-science. Clearly not aiming for subtlety, the first girl declares that GMOs are “monstrous.” To apparently explain what she means, the second girl says that, “They take a gene from a fish and put it into a tomato.”

No, “they” don’t.

The “fishmato” has been a persistent myth of the anti-GMO lobby. It is both untrue, and unscientific even if it were true. The myth comes from the fact that in the 90’s there were experiments on putting a fish gene into a tomato in order to make it frost tolerant. The tomato was never marketed. In fact, at present there are no GMO tomatoes on the market.

But even if it were – so what? This is a perfect representation of the “frankenfood” strategy of the anti-GMO lobby. Fish and tomatoes, just like people and bananas, already share about 60% of our genes. There is nothing that makes a fish gene a fish gene, other than the fact that it is in a fish. They won’t make tomatoes have scales or taste fishy.

The reason the fishmato myth will not die, however, is because it is a useful way to manipulate people by triggering a vague sense of disgust.

This also represents the false dichotomy at the core of organic anti-GMO propaganda. In their narrative, food is divided into two clear groups. The first group is natural and wholesome. The second group – GMOs – are unnatural and scary. This division is a fiction.

In reality almost all food consumed by humans has been significantly modified using a range of methods. There is no clear dividing line between “GMO” and not “GMO”. If you want clear distinctions, you will have to delve deeper into specific methods.

Some equate GMOs with transgenic modification – inserting a gene from a distant species. However, that is just one form of genetic modification, and as I pointed out there is nothing inherently risky or unnatural about it. It even happens all the time in nature through horizontal gene transfer.

But there are a host of other methods, including forced hybridiation, mutation farming using radiation or chemicals that mutate seeds, and biotechnology that does not involve a transgene, such as using genes from related species, or just removing, silencing, or altering an existing gene.

In the organic anti-GMO narrative, however, there is a bright line in which mutation farming using radiation is natural and wholesome, and silencing a gene makes food “monstrous.”

An interesting wrinkle to the story of the Stonyfield video is that there was a significant backlash against the video in the comments. This is a good sign, showing that exposing the lies of the anti-GMO lobby is getting some traction.

Stonyfield responded by doubling down on their intellectual dishonesty – they deleted many of the critical comments claiming they were from “trolls.” Yet some of those deleted comments were from scientists with a publicly verifiable identity.

Dismissing (and deleting) critical comments as trolls is the equivalent of reflexively yelling, “Fake news” at any facts or opinions you don’t like.

They then tripled-down on their dubious behavior by claiming that they used an (undisclosed) database of fake names to locate the troll comments. Right.

In their open letter defending all this, Stonyfield digs themselves even deeper into anti-GMO propaganda. They explicitly equate GMOs with use of herbicides because that is what the current majoriy of GMO crops are for (herbicide tolerance). But this is irrelevant to the GMO debate, because GMOs (an arbitrary category) are essentially the result of a range of technologies, and cannot be equated to one specific application, even if it is currently the most common.

Further, they conveniently buy into anti-glyphosate fearmongering. Glyphosate is actually a relatively safe herbicide, with no credible link to cancer. This strategy also brings up the fact that organic farming can and often does use pesticides, as long as they are deemed “natural”, and many of them are far more toxic than glyphosate.

They then have the gall to call for labeling as if they are pro-transparency and people have the right to be informed, all the while misinforming the public about GMOs and organic farming.

They further link to anti-GMO propaganda sites as if they are credible or independent scientific sources. Meanwhile, actual scientific organizations have all come down on the side of the safety of GMOs.

This one little video is a microcosm of all the problems with using a false narrative and fearmongering in order to market pseudoscience, and how to exploit social media to forward that narrative and dismiss your critics.

At least Stonyfield was incompetent enough in their execution to make this strategy obvious. Hopefully in the end this will further expose the lies of the anti-GMO organic lobby.

Categories: Skeptic

False Alarm

Mon, 01/22/2018 - 8:07am

On January 13 a state-wide alarm was sent out in Hawaii warning of an incoming missile. “BALLISTIC MISSILE THREAT INBOUND TO HAWAII. SEEK IMMEDIATE SHELTER. THIS IS NOT A DRILL,” the emergency alert read. For the next 38 minutes the citizens of Hawaii had the reasonable belief that they were about to die, especially given the recent political face off with North Korea over their nuclear missiles.

However, within minutes the Governor and the Hawaiian government knew that this was a false alarm, resulting from a technician hitting the wrong button. So, there are two massive failures here – sending out the alarm in the first place, and taking 38 minutes to officially send out the correction. (They did tweet that it was a false alarm, but the retraction was not generally known and it wasn’t certain that it was official.)

Then the media was shown a screen capture of the menu options the operator would have seen (image above). However, this is not an actual screen capture of the actual menu, but something similar to what the operator would have seen. So some headlines read that the screen capture was fake, but is does represent what the operator would have seen. You are probably now as confused as that operator.

The Hawaiian state government did review the situation and “fixed” it by adding a second operator who has to confirm any real missile warnings. They also added a menu option to issue a false alarm message – because there previously wasn’t one, and that is why it took 38 minutes to issue the false alarm.

While these steps are good, they are a long way away from addressing the real problem. What I think this represents is the general reality that our technological civilization is more complex than we can optimally manage. We simply don’t have the culture of competency necessary to keep things like this from happening.

It seems to me that in general people have a child-like assumption of competency for any large institution. This assumption is reinforced by dramatic movies showing a level of competency and control that is really a fantasy. Institutions are just made of people, who are incredibly flawed and limited.

Atule Gawande wrote about this in The Checklist Manifesto. Essentially we have historically dealt with complexity through training, creating professionals with incredible knowledge and technical skill able to handle complex technology or situations. This, of course, is often necessary. But, Gawande argues, we have passed the point where training alone can deal with the complexity we face, resulting in error.

Further, in many situations minor errors can have catastrophic results – crashing a plane, operating on the wrong body part, or sending out a false alarm. In such situations we need error minimization orders of magnitude beyond what a mere mortal can accomplish. So how do we do this?

Gawande recommends the humble checklist – a list of procedures to be carried out in order, and checked off to insure that nothing is missed. The checklist works, and is increasingly used in medicine and elsewhere – but perhaps not everywhere it should.

Error minimization is also accomplished through redundancy, which I have heard referred to as the Swiss cheese model. Every person is like a slice of Swiss cheese, with holes. If you line up several slices, however, any one hole is less likely to go all the way through. In other words, it is less likely that two people will make the same uncommon mistake at the same time. The probabilities of failure multiply, reducing the error rate by orders of magnitude.

What the missile false alarm event shows is that there are other layers to error minimization, and increasingly that means having a computer user interface that is designed to be user friendly, intuitive, and to minimize errors.

I think anyone looking at that screen capture will have sympathy for the poor operator. Sure, he screwed up. But in a way he was set up for failure by the system. The system had holes, and he was just the unlucky chump to fall through one of them in a very public way.

Anyone who works for a large institution will be familiar with such situations. Your work place is likely not uniquely incompetent, but is probably fairly typical of every workplace out there, which can be a scary thought. Errors like hitting the wrong choice on that menu must happen all the time. This error, however, happened to be affect an entire state in a dramatic way. The error itself was not dramatic, only the result.

Creating an intuitive and optimized user interface is an art form and a science unto itself, and it is amazing at this point in computer technology that it is so often neglected.

I use the Epic electronic medical system, which is used by many large medical institutions. It is huge in the industry – and the user interface is terrible. The arrangement of information and options on the screen is not intuitive or optimized, there is often too much information that is unnecessary, and processes are unnecessarily complex.

Further, user warnings are terrible. You get warnings when they are unnecessary, and you don’t get them when they can be helpful. So you get warning fatigue, and tend to just click through warnings that are unhelpful, making it more likely to miss an actually useful warning.

So I totally sympathize with this poor operator who faced that terrible menu that was not organized in any way, did not have unambiguously descriptive labels, and did not include a real warning to let them know unequivocally what they were about to do. Apparently they just got an “are your sure” button, like we get many times a day just for doing common computer operations- completely worthless.

It is obvious that the software being used had no serious user interface design, no failure analysis, risk assessment, or error mitigation. If reports in the wake of this incident are accurate, this is typical of government applications, which seems plausible.

And all of this is just one tiny slice of our complex technological civilization. The entire field of risk assessment needs to be taken more seriously, and should be ubiquitous in any large organization.

And please, software developers – hire dedicated user interface experts. Your regular software engineers cannot do this. Really. The difference is between an amateur B-movie and a professional film made by industry experts. There is a lot of knowledge, skill, and nuance that goes into communicating with people, whether it is through film or a user interface.

Any software that is used to prescribe medication, or send a missile launch warning, should be tweaked as hell, and frequently reviewed and updated, with feedback from the actual people using the software. You also can’t fix a bad user interface through training alone.

The missile episode is also an example of how the stakes are getting higher. Our systems are not only complex they are increasingly interdependent, and running critical aspects of our lives.

In short we need to have thoughtful systems in place that allow flawed humans to operate with minimal error, and those systems need systems to make sure they are optimized. This should be standard procedure, taken for granted as part of any process. That is the culture we need.

By coincidence I am in Hawaii this week on vacation. I will be seeing the Pearl Harbor memorial later today – that is another case history in the consequences of tiny errors in a system set up to fail.

Categories: Skeptic

The Dangers of Celebrity Culture

Thu, 01/18/2018 - 4:56am

Zooey Deschanel has a Facebook page where she gives advice on complex scientific topics. I love Deschanel as an actress and enjoy much of her work (particularly the otherwise mediocre movie version of the Hitchhiker’s Guide), but that does not mean I want to take advice from her on which foods I should eat.

Celebrity culture, in one form or another, has always been part of human society. Even chimpanzees will follow a charismatic leader, and it seems likely that humans are wired also to follow those we admire, and elevate them perhaps a bit too much. There is even research that shows that when we listen to a charismatic speaker the executive function part of our frontal lobes shuts down. We literally turn off our critical thinking when basking in the glow of our glorious leader.

Recognizing that this is part of the human condition is important. First, we need to be vigilant about surrendering our thinking to others. It’s also important to remind ourselves that everyone is a flawed human, and so constantly give those pedestals a reality check.

But that does not meant we should not admire and respect those who deserve it, or even look up to them for wisdom (as long as we maintain our critical eye). It does mean we need to choose carefully those we respect and follow.

Many people have written recently about the death of expertise. This is a concerning trend of lessening respect for those with genuine expertise, earned through years of study and experience, and often evaluated in some formal way. This may just be a historical trend swinging back and forth, and we happen to be going through a period of populist rejection of  authority. Regardless of cause, it is a dangerous trend. We live in an extremely complex technological civilization. Our lives literally depend on countless experts doing jobs we do not understand (or may not even know that they exist). It’s hard to know exactly how fragile the whole system is, but I don’t really want to find out.

But here is another point – while populists congratulate themselves for being independent thinkers and rejecting the authority of experts, they aren’t really. They are just replacing one set of authority figures for another. In many cases celebrity culture is stepping in to fill the void, and the result is not likely to be good.

In a recent commentary on the phenomenon, Michael Schulson points out:

As many celebrities have discovered, the combination of wellness culture, ethical consumerism, and Hollywood glamor can make for a potent — and profitable — media cocktail. Pioneers of the model include Gwyneth Paltrow’s Goop, a health and lifestyle brand, Jessica Alba’s Honest Company, and even Tom Brady’s TB12.

Exactly. I would add that sometimes health gurus become celebrities (Dr. Oz), and sometimes celebrities become health gurus, but the end result is usually the same. Paltrow’s Goop is probably the most successful example at this point, but there have been and will be others.

The very fact that Oprah’s name was seriously floated as a potential presidential candidate indicates how pervasive celebrity culture is. (I have already dealt with this nonsense.)

Spend any amount of time having discussions with those who follow any anti-science echochamber, an ideological belief, or a celebrity guru and you will see that they simultaneously rail against bowing to the authority of academics or scientists, as they are bowing to the authority of their guru or group.

We often make fun of those who claim they have “done their research” because what they really mean is that they have read a bunch of biased and cherry picked articles by hacks dedicated to an anti-scientific agenda.

Getting back to Deschanel – in one of her videos she literally advises people who are too poor to buy all organic to not eat certain vegetables, such as apples, tomatoes, grapes, peppers, and potatoes, because they may contain pesticides. This is a perfect example of how following fear and pseudoscience often leads to the exact opposite of what you want to achieve.

First, there is no evidence that eating fruits and vegetables poses any health risk due to pesticides. Residues are carefully regulated to be far below safety limits. Further, if you want to give yourself even more of a buffer of safety, then just wash your produce thoroughly.

Also, people on a limited budget tend to have worse diets, with real health consequences. Scaring them into avoiding cheap and abundant vegetables is really counterproductive. It also is a manifestation of privileged first-worlders imposing their nonsense on those with less privilege and causing harm. They have the luxury of wasting money on boutique food to make themselves feel better, but they should stop interfering with those for whom a healthful diet is not a given.

It also has to be pointed out that organic farming can and often does use pesticides. For marketing, they mostly use pesticides they can sell as “natural” – but they are usually more toxic than conventional pesticides, and have to be applied in larger amounts and more often. This is because they are not using the best pesticide, but ones that feel “natural” even if they are worse.

But Deschanel, steeped in Hollywood culture, and without any relevant actual expertise, is now perpetuating these marketing myths based on fear, and is giving bad advice. She is actually telling poor people to avoid certain vegetables in their diet, or waste money they really can’t afford on the worthless organic label.

I don’t mind if celebrities lend their fame to a cause, or give voice to a science documentary. That’s all good. But they should not confuse their celebrity with expertise, or wisdom, or really anything else. More importantly, the public should not make this mistake. I do think it is probably good advice to separate the art from the artists. Famous actors are good at acting, and I will enjoy their art – but I really don’t care about their opinions on science or health topics, or even their political opinions. If they want to be taken seriously on a topic other than acting, they will need to earn that right separate from their celebrity.

And in general – maintain a healthy skepticism toward any authority, and choose your authority figures wisely. Specifically, fame and even charisma should probably not even be criteria.

 

Categories: Skeptic

More Mental Illness Denial

Tue, 01/16/2018 - 5:15am

I was recently pointed to this article by Johann Hari in The Guardian that takes a critical look at depression and the treatment for depression. Unfortunately, it turned out to be nothing more than the usual mental-illness denial talking points, misdirection, and obfuscation.

As you will see if you follow the link above, this is a well-worn topic here. The basics are this – there are those, for various reasons, who are engaged in what I think qualifies as mental-illness denial. They include scientologists, because they push their cult/religion as an alternative to psychiatry. There are also those who follow Szasz who saw psychiatry as a mechanism for political oppression. I also find denial at times among rival professions who want to take psychiatry down a peg or two (often they just confuse their experimental expertise for clinical expertise – always a problem).

They all tend to have in common the core claim that “mental illness” is a fiction. How can thoughts be diseased? This is ultimately a straw man that confuses different types of illness. Some illness is based in biological pathology – cells are damaged, deteriorating, poisoned, genetically flawed, or essentially not functioning within healthy parameters for some reason. You can often see the pathology in a biopsy or measure it with some physiological parameter.

But not all illness is pathological disease. There are also disorders in which some biological function is outside of healthy parameters without clear pathology. The brain in particular is prone to this type of illness, and that is because brain function depends on much more than just the health of its cells (neurons and glia). Even healthy brain cells can be organized in such a way that their neurological function is compromised.

Let’s say, for example, that the anxiety circuitry in the brain is hyperactive creating spontaneous, unfocused, and debilitating anxiety. Now of course, anxiety itself is part of our natural neurological function. It serves a purpose. But excessive and spontaneous anxiety no longer serves a functional purpose, it just inhibits the ability to function. It is a mental disorder, in the absence of biological pathology.

Mental health deniers, however, twist themselves into logical knots trying to deny that there could possibly be anything about excessive anxiety that we can properly call an illness or disorder.

Like all campaigns of denial, there is also a range of approaches to denying the existence and implications of mental illness. At the extreme end you will find pseudoscience and conspiracy theories. At the milder end you will find softer denial, and denial that they are deniers. At this end there is the attempt to sound reasonable, and to conceal that at the end of the day they are engaging in motivated reasoning to deny the topic they oppose for ideological or other reasons. They give themselves away, however, by using the tactics of denial, and always flirting with the more extreme arguments.

For example, climate change deniers trying to sound reasonable will often acknowledge that the Earth is warming, we just can’t be sure that humans are causing it. But if you back them into a corner with evidence, they will acknowledge this but just deny that we can do anything about it. There is evidence that this behavior is rooted in “solution aversion” – in the end they oppose proposed solutions to climate change, and will deny the science only as much as they need to in order to oppose those solutions.

With mental illness denial, sometimes the motivation is psychiatry denial – opposition to the psychiatric profession. Of course you can do this by denying mental illness, but for those trying to seem reasonable you can also say you accept that there is such a thing, but then deny that we understand it well enough to treat it. Or you can simply deny the approach to mental illness of the psychiatric profession.

At this point I want to be clear – there are legitimate criticisms of psychiatric science and practice. Just as there are legitimate criticisms of medicine in general, and any applied science, including climate science. There is also no sharp demarcation between fair and legitimate criticism and motivated denial. You need some knowledge and judgement to see the difference at the fuzzy border. That is why I tend to characterize denialism as a process, try to define and understand the process as best as possible, and then be vigilant about the intrusion of denalism strategies at any level.

So let’s get back to Johann Hari’s article and see where I think he veers into denialism. Hari is writing about the difference between a depression disorder and normal grief. He is commenting on the DSM (the manual psychiatrists use to make diagnoses – a popular target among deniers):

The authors conferred, and they decided that there would be a special clause added to the list of symptoms of depression. None of this applies, they said, if you have lost somebody you love in the past year. In that situation, all these symptoms are natural, and not a disorder. It was called “the grief exception”, and it seemed to resolve the problem.

So, in order to avoid confusing normal grief with a depressive disorder the DSM included a grief exception. This is common in defining mental illness. The brain interacts with the environment, so if we want to decide if a certain pattern of mood, thought, and behavior is due to a brain disorder we have to rule out that it is just responding to environmental triggers. Like with the anxiety example above – anxiety is normal if you have something to be anxious about, but a disorder if it is spontaneous or clearly out of proportion to the stimulus.

Hari continues his narrative:

Then, as the years and decades passed, doctors on the frontline started to come back with another question. All over the world, they were being encouraged to tell patients that depression is, in fact, just the result of a spontaneous chemical imbalance in your brain – it is produced by low serotonin, or a natural lack of some other chemical. It’s not caused by your life – it’s caused by your broken brain.

This is an oversimplification to the point of being wrong. See above – depression is caused by life, and when it is, that is not a disorder. But if an evaluation rules out reasonable life causes of depression, then we are left with the possibility that there is something about brain function that may be causing depression. Also keep in mind that the depression, in order to be considered a disorder, has to interfere with one’s life. It has to cause “demonstrable harm.”

And now here is where Hari goes entirely off the rails:

The grief exception seemed to have blasted a hole in the claim that the causes of depression are sealed away in your skull. It suggested that there are causes out here, in the world, and they needed to be investigated and solved there. This was a debate that mainstream psychiatry (with some exceptions) did not want to have. So, they responded in a simple way – by whittling away the grief exception. With each new edition of the manual they reduced the period of grief that you were allowed before being labelled mentally ill – down to a few months and then, finally, to nothing at all. Now, if your baby dies at 10am, your doctor can diagnose you with a mental illness at 10.01am and start drugging you straight away.

Is he really claiming that a competent psychiatrist practicing within the standard of care would diagnose a client with mental illness and prescribe medication one minute after their child dies? You might be tempted to say he was using an extreme example to illustrate a point – but that misses my point. Making such a diagnosis is all about context.

Hari creates a neat little narrative here that serves his purpose of mental illness denial. In his narrative, psychiatrists removed the grief exception from the DSM because it was inconvenient. However, here is a passage from the DSM V that Hari neglects to mention:

Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual’s history and the cultural norms for the expression of distress in the contest of loss.

So what they really did was remove it from the list of criteria, which required putting a time limit on grief, and instead moved it to a note that was more open-ended and encouraged “clinical judgment.” Any fair and reasonable discussion of the psychiatric approach to mental illness and the evolution of the DSM should have contained this passage. But I guess it didn’t fit Hari’s neat little narrative.

After recounting his startling discovery that people are psychological beings with emotional needs (shocker), he finishes with this false dichotomy:

If you are depressed and anxious, you are not a machine with malfunctioning parts. You are a human being with unmet needs. The only real way out of our epidemic of despair is for all of us, together, to begin to meet those human needs – for deep connection, to the things that really matter in life.

This is a hopelessly simplistic approach to mental health, ironically as simplistic as the straw man “malfunctioning parts” approach he is criticizing. Rather, our mood, thoughts, and behavior are the net effect of a complex interaction between brain and environment. There are always a complex mix of psychological and psychiatric and sometimes neurological factors involved (rarely, it is a brain tumor). It takes care and clinical judgement to tease apart when someone just needs some counseling, or to make some practical changes to their life, or just time to process grief or other life events – and when they have a disorder that also needs to be treated in order to make it even possible for them to engage in therapy.

The DSM psychiatric approach to patients who have mental complaints, signs, or symptoms is to take a multi-tiered approach. First, rule out any underlying medical condition (make sure their anxiety isn’t due to hyperthyroidism, for example). Then assess their signs and symptoms in the context of their history to determine how much of it is likely to be due to life events. How much is personality. And how much, if any, may be due to some misfiring circuit in the brain.

This is really hard, and we have limited knowledge, but we have accumulated enough to take a practical approach to many patients and to help them improve their lives. This should include the full range of options available, including medication and counseling. To deny the role of medication can do great harm to those who may need it.

Categories: Skeptic

Oprah Would Be a Disaster

Mon, 01/15/2018 - 4:39am

I know that Oprah has not stated she is considering running for president in 2020 and the initial buzz about her is just a fantasy. But some of her people have stated that she would consider running, and it is possible that they are testing the waters. Let’s put the idea out there and see how the public responds.

Those who are enthusiastic about Oprah after her rousing speech at the Golden Globes have failed to fully appreciate what the real problem with Trump is (at least from this skeptic’s perspective). This is not about politics, and all the ways that Oprah is different than Trump don’t affect the ways in which she is the same – and those similarities are what I am primarily concerned about.

Marc Fisher, writing for The Citizen, describes what Trump apparently means when he calls himself a genius. Trump thinks that being smart is succeeding without trying. He congratulated himself on getting through school without ever really studying (like those other chumps). He admires instinct, his ability to feel in his gut what the answer is. He criticizes academics, and brags that the most important thing he learned at school was that academics don’t really know anything.

By all accounts that it his approach to the presidency. The very fact that he thought he could be president without any prior relevant experience betrays this attitude. It did not appear to bother him, or even occur to him, that being the executive of a large and complex government might requires skills and experience that he had never honed, or even tested. He thought he could sit in the Oval Office and just shoot from the hip, rely on his gut to divine the right answer to the country’s and the world’s complex problems. He would have a staff of eggheads to worry about the details.

Don’t confuse this approach with appropriate delegation to proper experts. Trump does not recognize experts, or the value of expertise, or apparently that there is even such a thing. The Trump presidency is an anti-intellectual assault on the very notion of objective knowledge, the benefits of hard intellectual work, and the very notion of expertise. That, to me, is the real threat to our society. It does not matter that Trump is enabling one side or the other of the political spectrum.

As if to demonstrate this point, the notion of Oprah as president presents the same problems. Sure, she has a different temperament and personality than Trump. But Oprah’s media career represents just as much of an anti-intellectual assault on expertise as does Trump, with perhaps a far greater negative impact on our society.

First, Oprah has no relevant experience. If she thinks she can walk into the presidency as an entry-level position, than clearly she does not respect experience itself. She must think that whatever qualities she has are more important than knowledge and experience (to be clear, I think both generic virtues and specific experience are important). I would consider part of the qualification for president a respect for the complexity of the job, and a willingness to put in the hard work that this respect deserves. The very fact that she thinks (if she does) that she could be president without prior experience, to me, is disqualifying. Run for governor or the senate, put in your time, then decide if the presidency is for you.

Another way in which Trump and Oprah are similar is their embrace of quackery (this, in my opinion, is a symptom of a deeper problem, the lack of respect for appropriate expertise). Trump is anti-vaccine and embraces conspiracy theories. Oprah has perhaps done more to fuel the anti-intellectual movement in our society than anyone else in the last few decades.

As others have already pointed out, she is responsible for making the likes of Dr. Oz, Dr. Phil, and Jenny McCarthy famous. She promoted all sorts of pseudoscience and nonsense, like The Secret, Deepak Chopra, New Age spiritual delusions, and every flavor of dangerous alternative medicine. Her show has largely been a platform for mainstreaming and promoting pseudoscience and fantasy at the expense of science and reason.

Collectively the beliefs that she promoted are premised on the notion that we do not have to carefully study the universe with scientific rigor, humility, and critical thinking. We can just feel the answer, listen to our guts, and wish our desires into reality.

If the left embraces this approach as the right has, then our descent into post-enlightenment magical thinking will accelerate. It would also indicate a general failure to fully appreciate the real lessons of Trump. Expertise, knowledge, and experience really do matter – no matter your personality or other qualities.

I have previously pointed out a more subtle version of this lack of proper respect for expertise, and that is the fact that I think our culture overvalues talent and undervalues skill. We tend to admire those with “natural talent” that succeed without having to try too hard. There are also subtle (or not-so-subtle) ways we denigrate those who work hard to succeed, as “grinds”, eggheads, or “book smart.”

Pychologists, however, have demonstrated that this approach is counterproductive. It is always better to focus on what you can do and what you can change, and not on those things beyond your control. You cannot control the talents you are born with. In a way, focusing on talent relieves us of the burden of having to try. When we think our success or position in life is beyond our control, we are less likely to do something about it.

Focusing on skill and knowledge, however, and recognizing their ability to help us succeed motivates us to work harder, and to take the step necessary to succeed. In fact, we should not focus so much on the goal as the process the get there. What is the next step? That is what matters.

To me Trump’s presidency is the perfect example of what happens when you overemphasize natural ability. Trump thinks his natural “genius” means he can succeed at anything without really trying. If the polls are any indication then at least a majority of Americans recognize that this is perhaps not such a good idea, especially for a job as complex and important as the presidency.

This is a good historic opportunity to reinforce this lesson. I don’t think most people would want a surgeon with the same qualities, and lack of respect for knowledge and technical skill.

Now we need to push back against this trial balloon of Oprah in 2020 to reinforce this core lesson. Even if this is not serious, it doesn’t matter. The idea is now out there. It is a thought-experiment if nothing else. It is therefore also a great opportunity to remind everyone the real lessons from Trump, and why Oprah, the Queen of pseudoscience, magical thinking, and anti-intellectualism, would be a disaster.

Categories: Skeptic

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