Posts Tagged ‘health’
it’s all about evidence – part 1
I wrote an open letter to a homeopath recently, and received an interesting response, which I’ve promised to deal with publicly. My letter was sent by email at the same time that it was posted on this blog, and this was followed by another couple of emails back and forth. Here they are.
Wesley Smith to myself, April 13 2015
Hi Stewart
I thank you for the courtesy of bringing your article to my attention.
Can you please publish the following corrections to your blog:
To the best of my knowledge, Wesley Smith has never made any claim to be a medical practitioner and I wish to correct any inference in my article “An open letter to a Homeopath” that Wesley Smith misrepresented his qualifications or is not suitably qualified under Australian law to practice or write about complementary medicine. At the time of publishing I was unaware that Wesley Smith is a AHPRA registered Chinese Medicine practitioner (CMR0001709253). Furthermore I withdraw any implication that the phrase “the depth of crazy in which our Wesley is mired” may suggest that Wesley is not of sound mind, or is not fit to either educate people about or practice complementary medicine. Furthermore I acknowledge that I have no knowledge of the appropriateness or otherwise of the qualifications of any of the practitioners at the Live Well Spa & Wellness Centre and therefore I withdraw any inference that any of Live Well’s practitioners may be practicing in their chosen fields without appropriate qualifications.Stewart I have absolutely no interest in debating you, please advise me when you have published the corrections.
Kind regards
Wesley
Myself to Wesley Smith, April 18 2015
Hello Wesley
At no place in my blog post did I write that you claimed to be a medical practitioner, I simply pointed out that you were not one, as far as I could ascertain. Whether you (or your colleagues) are permitted under law to practise complementary medicine is neither here nor there, and I didn’t address that matter in my article. My concern is to point out that homeopathy is not a valid treatment, a view with which the NHMRC concurs. Nor are the other treatments I mentioned in my piece, none of which have scientific evidence to support them. I will of course not be making any changes to my article. Of course it doesn’t surprise me that you absolutely don’t want to debate me, as it would absolutely not be in your interest to do so.
Regards
Stewart Henderson
Wesley Smith to myself, April 20 2015
Hi Stewart
I would have had absolutely no concern if you kept your criticism focused on homeopathy or acupuncture. I don’t agree with you but I’m hardly going to loose sleep over that.
My concern is that you were lazy with your research and published your opinions as if they were fact. You also weakened your argument when you made it personal by disparaging me, Live Well and it’s practitioners. Not only is that sloppy writing and a lazy way to make an argument it is also defamation. I have given you the opportunity to make the appropriate corrections which you have rejected, therefore I will pursue the matter via legal action.
Stewart, my research into your background tells me that you have an arts degree, it’s interesting that you choose to write about a topic for which you seem to have no qualifications. Apparently you work, or have worked at Centacare in Adelaide? Their website homepage states “we believe that everyone has the right to be treated with respect and dignity.” Sounds like great advice and perhaps a tenet you personally would do well to reflect upon especially when dealing with people with whom you disagree.
Kind regards
Wesley
Myself to Wesley Smith, April 23 2015
Dear Wesley
Thanks for your response, which I will be posting in toto on my blog in the near future, together with my response. Your complete lack of interest in addressing the matter of evidence, which was clearly the issue of my blog post, is well noted. I don’t wish to have a private email correspondence with you, as I’m interested in complete transparency and openness. I’ll address all your ‘concerns’ on my blog, with my usual gusto and good humour.
Thanks
Stewart
So now we’re up to date, and I’ll try to suppress the sense of disgust and contempt I feel for this individual, and deal with the issues.
Firstly, let’s look at Wesley’s email number 1. It is, of course, intended to be threatening – ‘make these corrections to your blog, or else…’. The first ‘correction’ is to my ‘inference’ (it looks like old Wesley has been consulting a lawyer) that Wesley has been claiming to be a doctor when he isn’t. As I pointed out in my response, I made no such inference. The point is, when someone heads up an institution called the ‘Live Well Spa and Wellness Centre’, any reasonable soul might expect that individual to be a medical practitioner, working with a staff of medical practitioners. In fact that was exactly what I expected (oh and I think a court of law would agree, Wesley). Imagine my surprise when I found that there were no MDs on the premises!
The second ‘correction’ he wanted was the removal of the phrase ‘the depth of crazy in which our Wesley is mired’, because it suggested he wasn’t of sound mind. I’ll look more closely at that ‘depth of crazy’ shortly, but first I’ll make the obvious point that people believe all sorts of crazy things (though they don’t usually make their living out of them) – that the moon landing was a fake, that September 11 was an inside job, that vaccines cause all sorts of diseases, etc, but we don’t think they should be committed, we just try to get them (usually unsuccessfully) to think more reasonably. I’ve tried to do this with Wesley by pointing out the absurdity of homeopathy from a scientific perspective – again unsuccessfully, because he’s completely unwilling to even discuss the matter.
When I wrote of the ‘depth of crazy’, I really meant it, and this is not my opinion. My opinion isn’t worth a pinch of shit, actually, and nor is Wesley’s. All that matters is EVIDENCE.
EVIDENCEEVIDENCEEVIDENCEEVIDENCEEVIDENCEEVIDENCEEVIDENCEEVIDENCEEVIDENCEEVIDENCEEVIDENCEEVIDENCEEVIDENCEEVIDENCEEVIDENCEEVIDENCEEVIDENCEEVIDENCEEVIDENCEEVIDENCEEVIDENCEEVIDENCEEVIDENCEEVIDENCE
Get it, Wesley?
So let’s do a review of the treatments Wesley’s clinic, or whatever he calls it, offers.
Homeopathy
I gave a fairly full account of homeopathy here, where I referenced Dr Ben Goldacre’s Bad Science, Chapter 4 of which gives an even more comprehensive account of the pseudoscience. I’ve also written more recently about it here, and of course in my criticism of Wesley Smith. I’ve also referenced Wikipedia’s excellent article on Homeopathy, and while I’m at it I’d like to defend Wikipedia as an excellent, and well-referenced source of reliable scientific information. If you feel unsure about what it presents, you can always check the references for original sources. I should remind readers, too, that Wikipedia has been put under pressure by practitioners of ‘holistic medicine’ to give more credence to their methods, and its founders and gatekeepers have heroically refused. I won’t go into detail here, but the story is well-presented by Orac on his Respectful Insolence blog.
So I’m not going to rehash the absurdity of homeopathy here, but since Wesley makes the claim that I was ‘lazy with my research’ and ‘published my opinions as if they were fact’ (when in fact I focused entirely on the NHMRC’s comprehensive and negative findings regarding the practice), I will give here a list of just some of the books, academic papers, scientific articles and government and medical society factsheets that report negatively on the multi-million dollar homeopathy industry, and pseudoscience in general, as well as the major figures in debunking medical pseudoscience. They’re in no particular order.
Dr Ben Goldacre, Bad Science, esp Chapter 4 ‘Homeopathy’ – Dr Goldsworthy works for the NHS in Britain and is a broadcaster, blogger and writer on science-based medicine
Raimo Tuomela, ‘Science, protoscience and pseudoscience’, in Rational changes in science.
Stephen Barrett, M.D, ‘Homeopathy, the ultimate fake’, on Quackwatch – a well-referenced site, but note the hilarious-sad reader responses!
Orac, aka Dr David Gorski – Gorski is a surgeon and scientist, and writer of the Respectful Insolence blog, which deals mostly with the health claims of pseudo-scientists. His posts on homeopathy are too numerous to mention here, just type in homeopathy on his blog.
Edzard Ernst, “A systematic review of systematic reviews of homeopathy”, and “Homeopathy: what does the ‘best’ evidence tell us?’ – Ernst, a former professor of complementary medicine, has published innumerable articles on the subject in academic journals. He co-wrote Trick or treatment? with Simon Singh, which deals critically with homeopathy, acupuncture and various other pseudoscientific treatments. His emphasis on scientific evidence has made him many enemies among the CAM (Complementary and Alternative Medicine) camp.
The Cochrane Collaboration – an independent, non-profit NGO – partnered since 2011 with the WHO – in which over 30,000 volunteers work together to provide the best healthcare evidence.
Shang et al, ”Are the clinical effects of homoeopathy placebo effects? Comparative study of placebo-controlled trials of homoeopathy and allopathy”, The Lancet 366 (9487): 726–732 – This study, conducted by a number of scientific collaborators, is regarded as one of the best and most relevant studies available for proof of homeopathy’s lack of efficacy. To quote from its conclusion: ‘Biases are present in placebo-controlled trials of both homoeopathy and conventional medicine. When account was taken for these biases in the analysis, there was weak evidence for a specific effect of homoeopathic remedies, but strong evidence for specific effects of conventional interventions. This finding is compatible with the notion that the clinical effects of homoeopathy are placebo effects’.
World Health Organisation – the WHO has warned against the use of homeopathy for major diseases, though, generally speaking it has taken a softly, softly approach to the pseudoscience, presumably for political reasons. Here and here are reports about the WHO’s warnings.
NHMRC – Australia’s National Health and Medical Research Council. It has conducted a comprehensive review of homeopathy, which I reported on in my criticism of Mr Smith’s ‘wellness centre’.
Science-based medicine and the FDA (the US Food and Drug administration). The Science-based medicine blog, contributed to by a number of writers, is dedicated to expose as quackery everything that Mr Smith and his ilk are promoting. The report linked to above criticises the FDA for abdication of responsibility in dealing with homeopathy. It also points out that American pharmacists are calling for tighter regulations. Homeopaths have had it too easy for too long. The FDA is finally beginning its own investigation into the pseudoscience.
I could go on – there are many many more articles and sites I could mention, but you get the point. Homeopathy is a joke, and there are many videos poking fun at its ‘science’ – for example, here, here and here. A movement designed to expose its fraudulence, the 10:23 campaign, had people ‘overdosing’ on homeopathic pills, which usually have warnings about dosage levels on the bottles(!) And yet we still have people buying into this shite – quite possibly in increasing numbers.
I don’t know Mr Smith personally. It might be that he’s a very nice if deluded fellow who treats his clients very well, adding to the placebo effect of his ‘remedies’. The placebo effect appears to be very real and we’ve only just begun to investigate its power. On the other hand, Mr Smith may be a charlatan who is cynically exploiting the vulnerability of his rich but deluded patients – his ‘wellness centre’ is in a leafy suburb of Canberra, not exactly the poorest region of Australia. Of course it’s more likely that he’s a bit of both – we deceive others best when we’ve already deceived ourselves.
However, to judge by his email responses, Wesley isn’t as much of a sincere believer as he should be, because he’s far far more concerned with protecting his reputation and with making threats, than with exploring the evidence, and thence, the further application of these homeopathic treatments (I mean, if the ‘like cures like, in infinitesimal doses’ system works, then why couldn’t it cure every cancer known to humans?). In my earlier post I suggested to him an exciting project of getting his fellow homeopaths and their satisfied clients together to ‘crowd fund’ research which would prove homeopathy to be true once and for all. And yet Wesley doesn’t even effing mention the idea. AMAZING!!!!
Well, not, actually. Mention this idea to any homeopath, and the response would be the same. They’re totally uninterested in any real research. Testimonials and anecdotes are enough for them. They just want the evidence to be less rigorous – less real and more ‘imaginary’.
Wesley has made threats about defamation, presumably because I wrote that he’s mired in crazy – which he is. This post is already too long, so I’ll investigate the other crazy treatments he and his team offer in later posts, starting with acupuncture. But as to his threats, the man must be living on another planet if he’s not aware of the many websites, some of which are mentioned above, dedicated to exposing the pseudoscience practiced by people like himself, for financial gain. They generally use far harsher language than I have. If you’re going to set up a practice devoted to procedures which seem to share only one feature – that none of them are accepted as established science – then you’ll need to develop a thicker skin, even if you can’t develop any sensible arguments to support them.
And one more thing – Wesley has tried to cast aspersions on me as a mere English graduate. I think on my ‘about’ page I describe myself as a dilettante, which most certainly and proudly is what I am. However, as a blogger, I suppose my official position is that of a journalist. Freelance of course, with the emphasis on ‘free’, as I’ve never earned a cent from it. No defamation action could ever succeed against a journalist who’s trying to expose ‘sharp practice’ through the investigation of evidence, but perhaps Wesley thinks he can intimidate ‘small fry’ like me with his threats and arrogance. I don’t get much traffic here because I’m hopeless at and positively resistant to networking. But I do know how tight-knit and supportive the sceptical community is when anyone tries to threaten it as Wesley has, because I’ve been observing it for years, and if Wesley tries any further intimidation, I suppose I’ll have to pull my finger out and start letting people know what’s happening. It’ll probably do me a power of good.
Anyway, in later posts I’ll be looking at acupuncture (briefly, as I’ve already dealt with this one before), cupping, kinesiology, bowen therapy and other treatments offered by Wesley and his team.
the myth of holistic medicine
It does get my goat rather that so-called naturopaths, in spite of having varied and often contradictory therapies, love to call themselves practitioners of holistic medicine. It’s a feel-good term that, like spirituality, seems to make a virtue of its own vagueness. Of course, holistic medicine can be defined in a superficial sense – it’s treating the whole person, right? But how does that work in reality, and how do naturopaths manage it?
Well, the obvious answer is, they don’t. It’s nothing more than a propaganda term.
Clearly, holistic, whole-person treatment would be fabulous if it could be achieved, but it would entail not only knowing the whole anatomy and physiology of the client, but her psychology and her entire medical history from birth, and even before. Would there be any other way of treating ‘the whole person’?
Personalised medicine may in fact become the way of the future – I’ve heard as much – but that has nothing to do with naturopathy. That has to do with science – your personal microbiome, your heart rhythms, your cholesterol, your triglycerides, your lung function, your bowel movements, your bone density (not to mention your sequenced genome), taking more responsibility for those things as far as is possible and in co-operation with healthcare providers. Naturopathy is something else altogether – it’s about herbs instead of pills (unless they’re homeopathic), ‘age-old’ treatments such as reflexology and TCM rather than invasive tests and vaccinations, getting in tune with or detoxifying your body rather than taking impersonal prescriptions to your local impersonal pharmacist.
So the question is – how did taking an entirely chemical herbal treatment from a naturopath come to seem more holistic than taking a chemical such as theophylline prescribed by your specialist?
I don’t see how a naturopath would or could treat a client as a ‘whole person’ any more than a conventional GP could. Limited info, limited time, it’s the same whether your treatments are science-based or traditional. But I do know at least one happy client who swears by her naturopath, who really does treat the whole person, unlike the medical establishment, according to her. I haven’t pressed her to explain this, but I have my own nasty theory. The woman is clearly obese, and wouldn’t take kindly to being told so, and she’s found a practitioner whose greatest skill is to tell her everything but what she most needs to hear. At last, someone who really understands her, who really listens and accepts her own expertise about her own body. And it must be said that many doctors, full to the brim of years and years of training and practice, do sometimes treat their clients in an offhand or specimen-like way. The psychological effects of healthcare practice are surely underestimated. So many people, but especially the unhealthy, want to be seen as, or made, whole. ‘Holistic medicine’ therefore, makes for a very effective propaganda label.
Yet many treatments that eagerly make use of the holistic banner are about as far from being individualised as can be imagined.
Acupuncture supposedly manipulates your ‘chi’ or ‘qi’, a system of energy flow that, if it existed, could be individualised to the client. Some clients might have a different chi from others, just as we have different blood types, different hormonal levels, different cholesterol levels, different insulin levels, etc, all of which can be measured. But acupuncturists don’t measure our chi levels and give us a read-out. Why ever not? Surely that would be the holistic, personalised thing to do. The fact is, nobody, in the supposedly thousands of years of acupunctural history, has ever thought to isolate this energy force and describe its wave function or the molecules or particles associated with its action. Nobody has even shown the slightest curiosity about the physical properties of what is advertised as a fundamental energy source in humans and perhaps all other living things. That’s fucking amazing – the only amazing thing I can say about acupuncture. Yet, apparently, there are particular points in the body where chi is more abundant, and that’s where you should stick your needles, and at a certain depth, otherwise you won’t be in touch with the chi. So acupuncture depends entirely upon chi being a physical, measurable entity…
Say no more. Your chi can’t be personalised and made a part of your whole-person profile because it doesn’t exist.
Homeopathy also likes to travel under the holistic banner, and you’ll find it advertised in all those brochures featuring glowingly healthy individuals, often dressed in white, meditating or staring lovingly at the sky-spirits. The trouble is, homeopathic treatments are designed to treat the illness, not the individual. The bogus ‘law of similars’ involves swallowing pills which are supposed to contain material ‘like’ whatever it was that made you sick. If that doesn’t sound very scientific, don’t blame me. It’s obviously a problem if you don’t know what made you sick, but the solution is simple. Just pay attention to your symptoms – say itchy skin or funny-coloured urine – and take pills containing a substance that produces similar symptoms. But hang on, won’t that just make you more sick? No, not at all, because the offending substance will be diluted to infinitesimal proportions. Okay, but won’t that render it useless? Ah but you’re clearly unaware of the ‘law of infinitesimals’ which defines a substance as increasing in potency the more it’s diluted. Welcome to the world of homeopathy, where the more truth is watered down, the more obviously true it becomes.
But the point I wanted to make here, before becoming entranced by the homeopathic mindset, was a simple one. Far from treating clients as ‘whole people’, it is solely concerned with physical symptoms. A homeopathic treatment would work just as well on a horse or a hedgehog as on a human. The client’s humanity, let alone her particular history or psychological make-up, isn’t a factor. It’s as far removed from holistic medicine as you can get.
I could go on – reflexology, iridology, reiki, chiropractic – these are all bogus, and the fact that they all jump eagerly onto the holistic bandwagon is further evidence of their crappiness. Holistic medicine is an impossible ideal, though personalised medicine, where you take personal responsibility to educate yourself about and keep records of your own health and physical maintenance, in collaboration with health specialists, is a great way to go. And that involves a lot more than just holding hands in a smiley circle.
the low-down on antioxidants
forget ORAC, just eat them coz they look so yummy
I’m going to risk alienating other colleagues here, but this post follows on from the last set in being inspired by work conversations, this time about plants and antioxidants. A plant was brought in by a staffer who apparently dabbles in naturopathy on the side, and its antioxidant properties were extolled. What do I know about antioxidants? Very little, except that some years ago red wine and various berries were being sold to us as containing life-enhancing quantities of these good molecules or whatever they are. It had something to do with binding to and neutralising ‘bad’ free radicals in our bodies. Of course I had no idea what free radicals were. Then later, via the Skeptics’ Guide to the Universe and other sources, I heard that the experts were back-tracking heavily on these life-enhancing properties.
So, what with being told in the staff room that antioxidants could cure cancer or some such thing, while elsewhere hearing that they’ve been wildly over-hyped, I’ve been considering for some time that I should do a post on these beasties, for dummies like me.
As usual, the first thing that greets me when I attempt to research this kind of thing is the pile of propadandist rubbish you have to wade through in order to find bona fide, science-based info sites. The good thing is that, over time, you get quicker at dodging bullshit.
I immediately homed in on a link saying ‘beware of antioxidant claims’, as being right up my alley. It took me to the ‘Berkeley Wellness‘ site out of the University of California. There I’m given the first definition – that an antioxidant is ‘a substance that helps mop up cell-damaging substances known as free radicals’, which leaves me hardly the wiser. I’m also told that selling products with claimed antioxidant properties is real big business in the US.
I’m also introduced to the ORAC (oxygen radical absorbance capacity) concept. My neighbour has an ORAC diet book and I’ve wondered what it meant. It seems that in the USA there’s a trend towards advertising the ‘antioxidant power’ of products based on ORAC scores – 7,300 ORAC units per 100 grams for a certain cereal, for example, or 6000 ORACs for a pack of corn chips. Are these numbers reliable, and what do they mean exactly?
Not much, apparently. The fact is that antioxidant interactions in the body are extremely complex and little understood. ORAC is only one of a number of different antioxidant tests used by different scientists in different labs, and even when they use the same test, such as ORAC, different labs come up with widely different results. Let me quote the Berkeley site directly:
Moreover, ORAC and other tests measure antioxidant capacity of substances only in test tubes. How well the antioxidants suppress oxidation and protect against free radicals in people is pretty much anyone’s guess.
A lot can happen to antioxidants once a food is digested and metabolized in the body, and little is known about their interactions. What has high antioxidant activity in a test tube may end up having little or no effect in the body. Preliminary research has found that when people eat high-ORAC foods, their blood antioxidant levels rise, but such results still don’t prove that this translates into actual health benefits.
The article ends with the usual smart advice. Choose a balanced diet, don’t eat too much, not too heavy on the meat, and with a fair quantity of whole grains, nuts and legumes, fresh fruit and veg, and you’ll get all the antioxidants and other nutrients you need. Actually, this article from I fucking love science, which gathers together expert advice on avoiding cancers, covers it all – keep your weight down, keep to the above-mentioned diet, exercise regularly in moderation, watch the sugar and salt intake and usually she’ll be right, whether it’s cancer, heart disease or whatever.
Not much more to say, really. But no doubt a lot more can be said about the science, and I’ll say just a bit about it here. Antioxidants, as the name suggests, are compounds that reduce oxidation in the body. Free radicals – unstable molecules – are produced when oxygen is metabolised. Free radicals remove electrons from other molecules, damaging DNA and other cellular material. They’re necessary for the body to function, but an overload can cause serious problems, and that’s where a common-sense diet comes in – though there are other factors which can bring about an overload, including stress, pollution, smoking (pollution by another name), sunlight and alcohol. Everything counts in large amounts.
Antioxidants come in many varieties. Nutrient antioxidants found in a variety of foods include vitamins A, C and E, as well as copper, zinc and selenium. Non-nutrient antioxidants, believed it have even greater effects (raising antioxidant levels), include phytochemical such as lycopene in tomatoes, and anthocyanins, found in blueberries and cranberries. I can’t find any clear info on the difference between non-nutrient and nutrient antioxidants, and it doesn’t appear to be important. There is, of course, a lot of ongoing research on all of this, and it would be easy to get obsessed with it all, raising your stress levels and sending those free radicals zinging through your body in legions. And if that’s what you want, why not buy this book, for a small fortune, and find out all that we currently know about how frying food affects its nutritive value, with particular attention to antioxidants. Of course, by the time you’ve finished it, it’ll likely be out of date.
There’s a ton of material out there on antioxidants, but Wikipedia is an excellent place to start, and to finish. One key piece of advice, in this as with other matters of diet, is – don’t rely on supplements when you can simply improve your diet (recent large-scale trials have shown they don’t work anyway). Get what you need from real food, as far as you can.
on vaccines and type 1 diabetes, part 3 – causes
As mentioned earlier, it’s not precisely known what causes diabetes type 1, more commonly known as childhood diabetes. There’s a genetic component, but it’s clearly environmental factors that are leading to the recent apparently rapid rise in this type.
I use the word ‘apparent’ because it’s actually hard to put figures on this rise, due to a paucity of historical records. This very thorough and informative article, already 12 years old, from the ADA (American Diabetes Association – an excellent website for everything to do with the evidence and the science on diabetes), tries to gather together the patchy worldwide data to cover the changing demography and the evolving disease process. At the beginning of the 2oth century childhood diabetes was rare but commonly fatal (before insulin), and even by mid-century no clear rise in childhood incidence had been recorded. To quote the article, ‘even by 1980 only a handful of studies were available, the “hot spots” in Finland and Sardinia were unrecognized, and no adequate estimates were available for 90% of the world’s population’. Blood glucose testing in the early 20th century was far from being as simple a matter as it is today, and the extent of undiagnosed cases is hard to determine.
There’s no doubt, however, that in those countries keeping reliable data, such as Norway and Denmark, a marked upturn in incidence occurred from the mid 20th century, followed by a levelling out from the 1980s. Studies from Sardinia and the Netherlands have found a similar pattern, but in Finland the increase from mid-century has been quite linear, with no levelling out. Data from other northern European countries and the USA, though less comprehensive, show a similar mid-century upturn. Canada now (or as of 12 years ago) has the third highest rate of childhood diabetes in the world. The trend seems to have been that many of the more developed countries first showed a sharp increase, followed by something of a slow-down, and then other countries, such as those of central and eastern Europe and the Middle East, ‘played catch-up’. Kuwait, for example, had reached seventh in the world at the time of the article, confounding many beliefs about the extent of the disease’s genetic component.
The article is admirably careful not to rush to conclusions about causes. It may be that a number of environmental factors have converged to bring about the rise in incidence. For example, it’s known that rapid growth in early childhood increases the risk, and children do in fact grow faster on average than they did a century ago. Obesity may also be a factor. Baffled researchers naturally look for something new that has entered the childhood environment, either in terms of nutrition (e.g. increased exposure to cow’s milk) or infection (enteroviruses). Neither of these possibilities fit the pattern of incidence in any obvious way, though there may be subtle changes in antigenicity or exposure at different stages of development, but there’s scant evidence of these.
Another line of inquiry is the possible loss of protective factors, as part of the somewhat vague but popular ‘hygiene hypothesis’, which argues that lack of early immune system stimulation creates greater susceptibility, particularly to allergies and asthma, but perhaps also to childhood diabetes and other conditions. The ADA article has this comment:
Epidemiological evidence for the hygiene hypothesis is inconsistent for childhood type 1 diabetes, but it is notorious that the NOD mouse is less likely to develop diabetes in the presence of pinworms and other infections. Pinworm infestation was common in the childhood populations of Europe and North America around the mid-century, and this potentially protective exposure has largely been lost since that time.
The NOD (non-obese diabetic) strain of mice was developed in Japan as an animal model for type 1 diabetes.
The bottom line from all this is that more research and monitoring of the disease needs to be done. Type 1 diabetes is a complex challenge to our understanding of the human immune system, and of the infinitely varied feedback loops between genetics and environment, requiring perhaps a broader questioning and analysis than has been applied thus far. Again I’ll quote, finally, from the ADA article:
In conclusion, the quest to understand type 1 diabetes has largely been driven by the mechanistic approach, which has striven to characterize the disease in terms of defining molecular abnormalities. This goal has proved elusive. Given the complexity and diversity of biological systems, it seems increasingly likely that the mechanistic approach will need to be supplemented by a more ecological concept of balanced competition between complex biological processes, a dynamic interaction with more than one possible outcome. The traditional antithesis between genes and environment assumed that genes were hardwired into the phenotype, whereas growth and early adaptation to the environment are now viewed as an interactive process in which early experience of the outside world is fed back to determine lasting patterns of gene expression. The biological signature of each individual thus derives from a dynamic process of adaptation, a process with a history.
However, none of this appears to provide any backing for those who claim that a vaccine is responsible for the increased prevalence of the condition. So let’s wade into this specific claim.
It seems the principle claim of the anti-vaxxers is that vaccines suppress our natural immune system. This is the basic claim, for example, of Dr Josef Mercola, a prominent and heavily self-advertising anti-vaxxer whose various sites happen to come up first when you combine and google key terms such as ‘vaccination’ and ‘natural immunity’. Mercola’s railings against vaccination, microwaves, sunscreens and HIV (it’s harmless) have garnered him quite a following among the non compos mentis, but you should be chary of leaping in horror from his grasp into the waiting arms of the next site on the list, that of the Vaccination Awareness Network (VAN), another Yank site chock-full of of BS about the uselessness of and the harm caused by every vaccine ever developed, some of it impressively technical-sounding, but accompanied by ‘research links’ that either go nowhere or to tabloid news reports. Watch out too for the National Vaccination Information Centre (NVIC), another anti-vax front, full of heart-rending anecdotes which omit everything required to make an informed assessment. The best may seem to lack conviction, being skeptics and all, but it’s surely true that the worst are full of passionate intensity.
There is no evidence that the small volumes of targeted antigens introduced into our bodies by vaccines have any negative impact on our highly complex immune system. This would be well-nigh impossible to test for, and the best we might do is look for a correlation between vaccination and increased (or decreased) levels of disease incidence. No such correlation has been found between the MMR vaccine and diabetes, though this Italian paper did find a statistically significant association between the incidence of mumps and rubella viral infections and the onset of type 1 diabetes. Another paper from Finland found that the incidence of type 1 diabetes levelled out after the introduction of the MMR vaccine there, and that the presence of mumps antibodies was reduced in diabetic children after vaccination. This is a mixed result, but as yet there haven’t been any follow-up studies.
To conclude, there is just no substantive evidence of any kind to justify all the hyperventilating.
But to return to the conversation with colleagues that set off this bit of exploration, it concluded rather blandly with the claim that, ‘yes of course vaccinations have done more good than harm, but maybe the MMR vaccine isn’t so necessary’. One colleague took a ‘neutral’ stance. ‘I know kids that haven’t been vaccinated, and they’ve come to no harm, and I know kids that have, and they’ve come to no harm either. And measles and mumps, they’re everyday diseases, and relatively harmless, it’s probably not such a bad thing to contract them…’
But this is a false neutrality. Firstly, when large numbers of parents choose not to immunise their kids, it puts other kids at risk, as the graph at the top shows. And secondly, these are not harmless diseases. Take measles. While writing this, I had a memory of someone I worked with over twenty years ago. He had great thick lenses in his glasses. I wear glasses too, and we talked about our eye defects. ‘I had pretty well perfect vision as a kid,’ he told me, ‘and I always sat at the back of the class. Then I got measles and was off school for a fortnight. When I went back, sat at the back, couldn’t see a thing. Got my eyes tested and found out they were shot to buggery.’
Anecdotal evidence! Well, it’s well known that blindness and serious eye defects are a major complication of measles, which remains a killer disease in many of the poorest countries in the world. In fact, measles blindness is the single leading cause of blindness in those countries, with an estimated 15,000 to 60,000 cases a year. So pat yourself on the back for living in a rich country.
In 2013, some 145,700 people died from measles – mostly young children. In 1980, before vaccination was widely implemented, an estimated 2.6 million died annually from measles, according to the WHO.
Faced with such knowledge, claims to ‘neutrality’ are hardly forgivable.
on vaccines and diabetes [type 1], part 2
Okay, before I look at the claimed dangers of vaccines in general, I’ll spend some time on diabetes, which, as mentioned, I know precious little about.
Diabetes mellitus, to use its full name, is a metabolic disease which causes blood sugar levels to be abnormally high. Some of the immediate symptoms of prolonged high blood sugar include frequent urination and feelings of hunger and thirst, but the disease can lead to many serious complications including kidney failure, heart disease and strokes. Diabetes is generally divided into type 1, in which the pancreas fails to produce enough insulin, and type 2, in which the body’s cells fail to process the insulin produced. Type 2, which accounts for some 90% of cases, can lead to type 1. There’s a third recognised type called gestational diabetes, a sudden-onset form occurring in pregnant women, which usually disappears after giving birth. As I’m not sure whether the claim about the MMR vaccine was related to type 1 or type 2, I’ll examine both.
type 1 diabetes and vaccination
A factsheet from Australia’s National Centre for Immunisation Research and Surveilance (NCIRS), a joint service of Westmead Hospital and Sydney University, and part of the World Health Organisation’s Vaccine Safety Net system of public information websites, summarises type 1 diabetes thus:
This is thought to be an autoimmune disease, where the immune system malfunctions to cause destruction of the insulin-producing cells in the pancreas. This is the usual type of diabetes in children, and requires treatment with insulin injections. Without insulin, people with Type 1 diabetes will die. Diabetes is thought to be due to an interaction between inherited and environmental factors, not all of which have been identified.
It goes on to describe an ‘unexplained’ increase in cases in Australia and many other (but not all) countries. There are regional variations in rates of increase, with higher rates in Northern European countries, lower in Asia and Africa, probably due to genetic factors. A number of environmental factors that may also contribute to the incidence of the disease have been studied, including breast feeding, infections, immunisation, nitrates and vitamin D. Breast feeding slightly reduces the risk of contracting diabetes, and drinking cow’s milk may increase the risk. As to infections, few have been proven to cause diabetes – though one of them, interestingly, is mumps. Diabetes incidence is affected by seasonal variation, and it’s likely that seasonal viral infections may trigger the onset of diabetes in some people. It’s also possible that some strong medications may compromise the immune system and so cause or promote the onset of the disease. High levels of nitrates in drinking water have been shown to increase the incidence.
The factsheet is entitled ‘Diabetes and vaccines’, so it deals head-on with the vaccination issue, and its conclusion is uncompromising: ‘No, there is no evidence that vaccines cause diabetes’. It cites 15 separate studies in its reading list, three of which are authored or co-authored by a Dr John Classen. These three are the only studies to suggest a link. Here’s the NCIRS response:
There have been a number of studies which have searched for links between diabetes and immunisations. The only studies suggesting a possible increase in risk have come from Dr John B Classen. He found that if the first vaccination in children is performed after 2 months of age, there is an increased risk of diabetes. His laboratory study in animals also found that certain vaccines, if given at birth, actually decrease the risk of diabetes. This study was based on experiments using anthrax vaccine, which is very rarely used in children or adults. Dr Classen also compared diabetes rates with vaccination schedules in different countries, and interpreted his results as meaning that vaccination causes an increased risk of diabetes. This has been criticised because the comparison between countries included vaccines which are no longer used or used rarely, such as smallpox and the tuberculosis vaccine (BCG).
The study also failed to consider many reasons other than vaccination which could influence rates of diabetes in different countries. Later, in 2002, Dr Classen suggested that vaccination of Finnish children with Hib vaccine caused clusters of diabetes 3 years later, and that his experiments in mice confirmed this association.
Other researchers who have studied the issue have not verified Dr Classen’s findings. Two large population-based American studies failed to support an association between any of the childhood vaccines and an increased risk of diabetes in the 10 years after vaccination. The highly respected international Cochrane Collaboration reviewed all the available studies and did not find an increased risk of diabetes associated with vaccination.
Dr Classen, it turns out, is an established anti-vaxxer who has more recently tried to prove a link between vaccines and autism.
I should point out also that the above factsheet, which is a few years old, doesn’t include a more recent study, on a very large scale, which showed a significant decrease in the incidence of type 1 diabetes with various vaccinations, including MMR.
Classen, though, wasn’t looking at the MMR vaccine, his claims were about the Hib vaccine, which prevents invasive disease caused by the Haemophilus influenzae type b bacterium. It also significantly reduces the incidence of early childhood meningitis. The NCIRS factsheet doesn’t even mention MMR, stating that the vaccines being debated are Hib, BCG (for tuberculosis) and hepatitis B.
The Philadelphia Children’s Hospital’s Vaccine Education Centre (whose director, Dr Paul Offit, is one of the world’s leading immunologists and experts on vaccines), cites a long list of studies – have a look yourself – which together find no evidence of a causal connection between diabetes (mostly type 1) and various vaccines. I’ve yet to find any published studies, even poorly conducted ones, that claim a specific negative connection between the MMR vaccine and diabetes. If anybody out there can point me to such a study, I’d be grateful.
So, while I wait for someone to get back to me on this (ho, ho), I’ll explore what immunologists and epidemiologists are saying about the rise of type 1 diabetes in recent decades in my next piece.
on vaccines and diabetes, part 1
A picture lies better than 1000 words
The other day, when I grumbled about anti-vaccination views during after-work drinks, a colleague said she was ‘semi-anti-vaccination’, specifically in relation to the connection between the MMR (measles, mumps and rubella) vaccine and diabetes. When I expressed skepticism, she challenged me on my knowledge of the science, which admittedly isn’t great – and I made matters look pretty bad for myself by egregiously claiming that children couldn’t be vaccinated before two years of age, instead of two months, a mistake I wouldn’t have made if I’d had kids of my own to vaccinate (or not), like most of my workmates.
When I inquired about this mysterious connection, I was curtly informed that it was nothing vague, but crystal clear causation. The link so often made between diabetes and increased sugar in our diets was bogus, I was told, because the timing didn’t make sense. Presumably the timing of the rise in diabetes did match the introduction of the vaccine, though such a correlation, if it exists, is far from proving causation. Proof would require that some component of the MMR vaccine was having a direct effect on our immune system in such a way as to increase susceptibility to the disease. If this were true, it would be absolutely sensational news, demanding domination of newspaper headlines worldwide. Extraordinary claims, as they say, require extraordinary evidence
Now, I must say that my sceptical antennae were immediately raised when I heard this claim, because I hadn’t heard it before, and as a regular reader of science magazines and relatively up-to-date popular science books, and a regular listener to science and scepticism podcasts, I’m reasonably sure I’m more scientifically literate than the average layperson. I’m aware, of course, of the vociferous anti-vaccination crowd and their claims of a causal connection between vaccines and autism, asthma and just about everything else that currently ails us. And I’m familiar too with the medical and immunisation experts, such as Doctors Paul Offit, Steve Novella and David Gorski, who are fighting the good fight against the tide of misinformation with evidence-based science. However, I’m perfectly willing to admit to a possible blind spot re diabetes, as it hasn’t personally affected me or anyone close to me.
I must say, though, that my ‘sceptical training’ enabled me to turn up this article from the Scientific American website within 5 seconds of looking (the first 4 seconds were spent avoiding the many innocuous-sounding websites that I knew to be fronts for anti-vaccination propaganda). The article reports on a review, conducted by the US institute of medicine, of over 1,000 published research studies on the adverse effects of eight vaccine types (including MMR). These vaccine types constitute the majority of vaccines against which claims have been made to the USA’s National Vaccine Injury Compensation Program (VICP). The report concludes that ‘vaccines are largely safe, and do not cause autism or diabetes’. Specifically on the MMR vaccine, the report had this to say:
The committee found that evidence “favors rejection” of discredited reports that have linked the MMR vaccine to autism and, along with the DTaP vaccine, to type 1 diabetes.
The DTaP vaccine covers three deadly bacterial diseases – diphtheria, tetanus and pertussis, or whooping cough.
End of story? Well, there’s always the possibility of a medical conspiracy, or of sloppy and complacent scientific analysis – doubtless influenced by Big Pharma. Needless to say, I’m very doubtful about this.
The final chapter of Dr Ben Goldacre’s landmark book Bad Science is entitled ‘The media’s MMR hoax’. It deals essentially with the claimed link between the vaccine and autism, but it has much of value to say about health scares in general and the role of the media in promoting them, either deliberately or inadvertently. For example, the MMR-autism connection scare was almost entirely confined to Britain at first, though it has since spread to the USA and Australia. It is almost unheard of in non-English-speaking countries, in spite of their using the exact same vaccine. Conversely, in France in the 1990s, the hepatitis B vaccine was being linked by some members of the public, supported by some in the media, to a rise in multiple sclerosis. No such link was being made outside of France, though the vaccine was the same everywhere. And there are many other examples to show that these scares are more culturally than scientifically based.
The anti-vaccination movement has a long and, it must be said, inglorious history, with the same sorts of arguments, and the same sorts of results, occurring from the beginning. Goldacre cites this interesting Scientific American article from 1888:
The success of the anti-vaccinationists has been aptly shown by the results in Zurich, Switzerland, where for a number of years, until 1883, a compulsory vaccination law obtained, and smallpox was wholly prevented– not a single case occurred in 1882. This result was seized upon the following year by the antivaccinationists and used against the necessity for any such law, and it seems they had sufficient influence to cause its repeal. The death returns for that year (1883) showed that for every 1,000 deaths two were caused by smallpox; In 1884 there were three; in 1885, 17, and in the first quarter of 1886, 85.
But, hey, measles is hardly smallpox, is it? It’s harmless. Is it worth disrupting our ‘natural immune system’ with vaccines just to protect ourselves against a few character-building ailments? Isn’t our over-reliance on vaccines potentially catastrophic for our bodies?
Well, I’ll delve more into such claims, and into diabetes more specifically, in my next piece.
bronchiectasis updated
A lot has happened regarding my bronchiectasis recently, so I need to write about it here to learn more about the medication I’m on and what it might be doing to me.
I posted on this a couple of weeks ago, and that was an update on my first important post on the subject. But last time I wrote about an ‘acute exacerbation’, as the literature has it, of my condition, and what I believed was its cause. As it turned out, I was completely wrong. My doctor thought it might be viral, while I was privately convinced it wasn’t. I was given a doctor’s certificate and told to take a couple of days off, because I could benefit from the rest and because I might be infectious. I reluctantly did so, but was back at work the next day when I noticed a missed private call on my phone. It took me another day to respond, and it turned out to be my doctor telling me that my sputum tested positively for two viruses, influenza A and a human rhinovirus. Oh dear. I had to take more time off work, and my doctor told me not to worry about the antibiotics (it was a small course and I’d finished them anyway) and gave me a puffer with 60 doses of Alvesco®, which is ciclesonide, a synthetic corticosteroid which ‘prevents the release of substances in the body that cause inflammation’, according to this website. This was on top of the ingestible steroids, the subject of my previous post, though I didn’t go into detail about those pills, which I’ll rectify shortly. He also gave me a nasal spray for my rhinovirus, and arranged for me to have a consultation with a professor of Chesty Things at the RAH Chest Clinic.
So I’d like to look more carefully now at the medication I’ve been prescribed, apart from the antibiotics.
Firstly, Panafcortelone®, 30 white tablets each containing 25mg of prednisolone, an anti-inflammatory steroid much like ciclesonide. The worry about steroids is that they can interact with other medications to our detriment. They can also weaken our immune systems under some circumstances. I must say, though, that I’ve never yet had an adverse reaction to any medication I’ve taken. There’s quite a list of ailments that can be adversely affected by steroid use, no matter whether it’s prednisolone, ciclesonide or any other steroid, it seems. However, they shouldn’t be confused with anabolic steroids, notoriously misused by athletes.
Secondly, the nasal spray, Avamys®. Its active ingredient is Fluticasone furoate, yet another corticosteroid. According to the accompanying leaflet:
Avamys is used to treat symptoms of allergic rhinitis including stuffy, runny or itchy nose, sneezing, and watery, itchy or red eyes. The effects are usually felt within the first day, although some people will not feel the effects until several days after first taking it.
I took this medication regularly as prescribed for 5 or 6 days, then dropped off, as I obviously felt a lot better. It contains 30 sprays, and I wasn’t told to keep taking it to the end, as far as I can recall. The leaflet says that ‘once symptoms are controlled you may be able to decrease your dose to one spray in each nostril per day [down from 2]’. However it says elsewhere: ‘Do not stop using Amavys or change the dose without first checking with your doctor’. So I’ll try to keep taking it, though I don’t feel that I need it. My symptoms have always been mild compared to the description above.
Thirdly, the first medication prescribed by the Professor. Spiriva® is the brand name for capsules containing 18 micrograms of tiotropium (equivalent to 22.5 micrograms of tiotropium bromide, monohydrate), which are punctured and inhaled rather than orally ingested. It’s an anticholinergic bronchodilator used generally to manage COPD (chronic obstructive pulmonary disease), but not for acute exacerbations. Here’s what Wikipedia has to say on anticholinergics:
An anticholinergic agent is a substance that blocks the neurotransmitter acetylcholine in the central and the peripheral nervous system. Anticholinergics inhibit parasympathetic nerve impulses by selectively blocking the binding of the neurotransmitter acetylcholine to its receptor in nerve cells. The nerve fibers of the parasympathetic system are responsible for the involuntary movement of smooth muscles present in the gastrointestinal tract, urinary tract, lungs, etc. Anticholinergics are divided into three categories in accordance with their specific targets in the central and/or peripheral nervous system: antimuscarinic agents, ganglionic blockers, and neuromuscular blockers.
Tiotropium is described as a muscarinic receptor antagonist (MRA), which means that it blocks the muscarinic acetylcholine receptor, found in the cell membranes of some neurons and other cells. Muscarinic receptors are divided into types, and the one I’m concerned with is the M3 receptor, which plays a role in bronchoconstriction.
Finally, the second medication prescribed by the professor is Nuelin™, aka theophylline (200mg in a sustained release form), which causes the muscle lining of the airways to relax, according to the leaflet. It is used to treat asthma and other conditions where breathing is difficult. According to the netdoctor site,
Theophylline is a type of medicine called a xanthine bronchodilator. It is used to open the airways.
Theophylline causes the muscles surrounding the airways to relax by a mechanism that is not fully understood. This allows the airways in the lungs to open.
In conditions where the airways tighten, such as asthma or chronic obstructive pulmonary disease (COPD, eg emphysema and chronic bronchitis), it is difficult for air to get in and out of the lungs. By opening the airways, theophylline makes it easier to breathe.
So all these medications are to help me breathe easier, but of course I’m hoping to be cured, and the professor, a lively and interesting gentleman, informed me that my lung function test, like the previous one earlier this year, came up very positively. That’s to say, my lung functionality is above average even for a normal person, so I’m really not having any difficulty breathing at all, I think… In fact, the professor mentioned a lung capacity of 106%, which doesn’t make much sense to me, and I forgot to ask for clarification (I’ve never given a student more than 100% for any test I’ve given them).
In any case I’m to go back to him around April for another consultation, by which time all these medicaments will be consumed. I think the hope is that some of the blocked areas as revealed on my CT scan will be a little less blocked. So maybe there’ll be another CT scan in the pipeline. The professor took me on a tour of my lungs via the previous scan, pointing out that because the whole of the right lung is affected by little blockages all through it, no operation would be possible, as might be the case if it was one localised very badly blocked region. presumably he was talking about an operation to remove a section of the lung. The left lung is not affected at all, which is apparently quite unusual.
Anyway, I’m always the optimist, and I’m hoping that maybe I can yet be cleared of all this gunk, and so cured.
a plague of mysteries
Well, maybe not quite
I’m writing this because of some remarks made in the workplace which – well, let’s just say they set my sceptical antennae working overtime. They were claims made about the bubonic plague, of all things.
Bubonic plague, dubbed the Black Death throughout European history, is a zoonotic disease, which means it spreads from species to species – in this case from rodents to humans via fleas. Actually there are three types of ‘black death’ plagues, all caused by the enterobacterium Yersinia pestis, the others being the septicemic plague and the pneumonic plague. Other zoonotic diseases include ebola and influenza. Flea-borne infections generally attack the lymphatic system, as does bubonic plague. The term ‘bubonic’ comes from Greek, meaning groin, and the most well-known symptom of the disease were ‘buboes’, grotesque swellings of the glands in the groin and armpit.
It wasn’t called the Black Death for nothing (the blackness was necrotising flesh). It’s estimated that half the European population was wiped out by it in the 14th century. If untreated, up to two-thirds of those infected will be dead within four days. With modern antibiotic treatments, the mortality rate is of course greatly reduced. The broad-based antibiotic, streptomycin has proved very effective. Of course treatment should be immediate if possible, and prophylactic antibiotics should be given to anyone in contact with the infected.
The plague is first known to have stuck Europe in the sixth century, at the time of Justinian. The Emperor actually caught the disease but recovered after treatment. It’s believed that the death toll was very high, but little detail has been recorded. The fourteenth century outbreak appears to have originated in Mongolia, from where it spread through Mongol incursions into the Crimea. An estimated 25 million died in this outbreak from 1347 to 1352. More limited outbreaks occurred in later centuries, and the last serious occurrences in Europe were in Marseille in 1720, Messina (Sicily) in 1743, and Moscow in 1770. However it emerged again in Asia in the nineteenth century. Limited for some time to south-west China, it slowly spread from Hong-Kong to India, where it killed millions of people in the early twentieth century. Infected rats were inadvertently transported to other countries by trading vessels, resulting in outbreaks in Hawaii and Australia. By 1959, when worldwide casualties dropped to under 200 annually, the World Health Organisation was able to declare the disease under control, but there was another outbreak in India in 1994, causing widespread panic and over 50 deaths.
So that’s a v brief history of the rise and fall of bubonic plague, but I’m interested in looking at early treatments and the discovery of its cause. For the fact is that, even in 1900, when the plague first came to Australia, there was no clear consensus among the experts as to its means of transmission, with many believing that it was as a result of contact with the infected. However, a growing body of evidence was showing a connection with epizootic infection in rats, and as it happened, work done by Australian bacteriologists Frank Tidswell, William Armstrong and Robert Dick, working for a new public health department in Sydney under Chief Medical Officer John Ashburton Thompson, established as a direct result of the plague outbreaks in Sydney from 1900 to 1925, contributed substantially to the modern understanding of Yersinia pestis and its spread from rats to humans. This Australian work was another step forward in the germ theory of disease, first suggested by the French physician Nicolas Andry in 1700, and built upon by many experimental and speculative savants over the next 150 years. The great practical success of John Snow’s work on cholera, followed by the researches of Louis Pasteur and Robert Koch, established the theory as mainstream science, but zoonotic infections, especially indirect ones where the infection passes from one species to another by means of a vector, have always been tricky to work out.
In fact it was in Hong Kong that the Yersinia pestis bacterium was identified as the culprit. A breakout of plague occurred there in the 1890s, and Alexandre Yersin, a bacteriologist who had worked under both Pasteur and Bloch, was invited to research the disease. He identified the bacterium in June 1894, at about the same time as a Japanese researcher, Kitasato Shibasaburo. The cognoscenti recognise that both men should share the honour of discovery.
What is fascinating, though, is that the spread of plague from Asia in the 1890s to various ports of the world in the earlier 20th century was very different from the spread of earlier pandemics. Did this have anything to do with science or human practices? Well, what follows is drawn from by far the most comprehensive analysis of the disease I’ve found online, Samuel Cohn’s ‘Epidemiology of the Black Death and successive waves of plague’, in the Cambridge Journal of Medical History.
Cohn’s research and analysis casts credible doubt on the whole plague story, specifically the assumption that we’re dealing with one disease, from the sixth century through to modern outbreaks. He recounts the standard story of three separate pandemics, in the sixth century with a number of recurrences, ditto in the fourteenth century, and in the nineteenth. However, the epidemiology of the most recent pandemic, definitely attributed to Y Pestis and its carrier the Oriental rat flea, Xenopsylla cheopis, is substantially different from that of pandemics one and two, a fact which, according to Cohn, has been obscured by inaccurate analysis of the records. Cohn’s own analysis, it must be said, is fulsome, with 30 pages of references in a 68-page online essay. He doesn’t have a solution as to what caused the earlier pandemics, but he asks some cogent questions. For my own understanding’s sake, I’ll try to summarise the issues in sections.
speed of transmission
Pandemic 3, if we can call it that, was a much slower mover than the previous two. It seems to have sprung up in China’s Yunnan province from where it reached Hong Kong in 1894. It was noted in the early 20th century that Y pestis was travelling overland at a speed of only 12 to 15 kilometres a year. This can be explained by the fact that Y pestis is a disease mainly of rats, though other rodents can also be infected, and rats don’t move far from their home territories. At this rate pandemic 3, even in a world of railways, cars, and dense human populations, would have taken some 25 years to cover the distance that pandemic 1 covered in 3 months. Pandemic 1 made its first appearance in an Egyptian port in 541 and quickly spread around the Mediterranean from Iberia to Anatolia. Within two years of first occurrence it had reached to the wastelands of Ireland and eastern Persia. Pandemic 2, believed to have originated in India, China or the Russian steppes, made its first European appearance in Messina, Sicily in 1347. Within three years it had impacted most of continental Europe, and had even reached Greenland. The fastest overland travel recorded for plague occurred in 664 (pandemic 1), when it took only ninety-one days to travel 385 kilometres from Dover to Lastingham (4.23 km a day)— far faster than anything seen from Y pestis since its discovery in 1894. Pandemic 2’s speed was similar, as Cohn details it:
like the early medieval plague, the “second pandemic” was a fast mover, travelling in places almost as quickly per diem as modern plague spreads per annum. George Christakos and his co-researchers have recently employed sophisticated stochastic and mapping tools to calculate the varying speeds of dissemination and areas afflicted by the Black Death, 1347–51, through different parts of Europe at different seasons. They have compared these results to the overland transmission speeds of the twentieth-century bubonic plague and have found that the Black Death travelled at 1.5 to 6 kilometres per day—much faster than any spread of Yersinia pestis in the twentieth century. The area of Europe covered over time by the Black Death in the five years 1347 to 1351 was even more impressive. Christakos and his colleagues maintain that no human epidemic has ever shown such a propensity to cover space so swiftly (even including the 1918 influenza epidemic). By contrast to the spread of plague in the late nineteenth and twentieth centuries the difference is colossal: while the area of Europe covered by the Black Death was to the 4th power of time between 1347 and 1351, that of the bubonic plague in India between 1897 and 1907 was to the 2nd power of time, a difference of two orders of magnitude.
All of which raises the question – why was pandemic 3 so much slower than the others? Could it be that Y pestis wasn’t the cause of the earlier pandemics?
mode of transmission
We know that Y pestis is a disease of rats, and we know that the Black Death was all about rats, so that’s an obvious connection, no? Well, according to Cohn, what we think we know is just wrong. ‘… no scholar has found any evidence, archaeological or narrative, of a mass death of rodents that preceded or accompanied any wave of plague from the first or second pandemic.’ I must say I found this incredible when I first read it, yet Cohn seems to have investigated the sources thoroughly.
Cohn notes that:
while plague doctors of “the third pandemic” discovered to their surprise that the bubonic plague of the late nineteenth and twentieth centuries was rarely contagious, contemporaries of the first suggest a highly contagious person-to-person disease. Procopius, Evagrius, John of Ephesus, and Gregory of Tours characterized the disease as contagious and, in keeping with this trait, described it as clustering tightly within households and families; the evidence from burial sites supports their claims.
Pandemic 2 made the word contagium popular among the general public, and the incredible speed of transmission became one of the principle signs of the Black Death, differentiating it, for example, from smallpox, which had some similar physical characteristics. This contagion suggests person to person contact, more typical of pneumonic plague, which is highly infectious and can be transmitted through coughing and sneezing. A later chronicler of pandemic 2, Richard Mead, writing in the 1700s, advised against crowding plague sufferers in hospitals, as it ‘will promote and spread the Contagion’. However, those treating pandemic 3 noted, to their surprise, that plague wards were the safest places to be, and that this particular plague rarely took on the pneumonic form.
Cohn notes that the earlier pandemics were often associated with famine. For example in Alexandria and Constantinople in 618 and 619 famine preceded the plague and appeared to spark it into life. However, pandemic 3, definitely caused by Y Pestis, tended not to thrive in situations of dearth and was instead fed by increased yields. Such yields lead to higher rat populations, and higher rates of possibly infected rat fleas and so higher rates of transmission to humans.
death rates
According to contemporary accounts the first pandemic wiped out entire regions, decimating the inhabitants of cities and the countryside through which it so swiftly passed. These accounts are backed up by archaeological and other evidence. It’s pretty clear that millions died in the second pandemic too. Compare this to the third pandemic, which spread so slowly and was limited to coastal areas and even just shipping docks. Restricted to temperate zones, this last pandemic resulted in deaths in the hundreds, with never more than 3% of an affected population dying.
symptoms
Although few quantitative records describe the signs or symptoms of plague for pandemic one, those that do (and Cohn cites 6 different ancient authors) are in general agreement in their descriptions of ‘swellings in the groin, armpits, or on the neck just below the ear’, the classic symptoms of bubonic plague. Procopius of Caesaria also observed that victims’ bodies were covered in black pustules or lenticulae. Pandemic 2, which begins with the Black Death of 1347-52, is marked, on the other hand, by extensive records, both professional and popular – writings about it were amongst the first forms of popular literature.
range and seasonality
Another problem for the view that this has all been the doing of Y pestis, is that pandemics 1 and 2 could strike all year round, but generally settled into a pattern of prevailing in summer in the southern Mediterranean and the Near East, which is not the best season for the flea vector X cheopis. The seasonal cycle of modern plague is quite different, and the range is much more limited.
So all this opens up a mystery. Scientists are agreed that we don’t have a clear-cut story of Y pestis causing horrific disease through rats and fleas over millennia (archaeological and other evidence suggests that rats were scarce in 14th century Europe) , but they’re much in disagreement about what the real story might be. If not Y pestis, then maybe a hemorrhagic virus (one of which causes ebola). Such viruses are notorious for their rapid transmission, their resurgences and their high mortality rates. Pneumonic plague, the more infectious, lung-infecting form of plague may also be implicated, but this doesn’t appear to agree with most of the described symptoms of pandemics 1 and 2. Other types of fleas, not associated with rats, as well as lice, are also being considered as possible vectors. Some geneticists believe that a variant of Y pestis may have been responsible. It looks as if genetic analysis is the most likely pathway to finding a solution.
This article got started, as I wrote at the beginning, because someone keen on naturopathy said something about bubonic plague in our staff room. Some plant she brought in, which had great anti-oxidant properties (she clearly hasn’t kept up with the latest findings on anti-oxidants) was also a cure for bubonic plague, or maybe it was a variant of the plant, and the person who discovered the secret of its healing properties died suddenly (presumably not from plague) and the secret was lost to us for centuries…
bronchiectasis and steroids
My bronchiectasis has just ‘acutely exacerbated’.
Today I’m off work because I’ve got another infection, the first since I finished the course of broad-spectrum antibiotics back in May. The symptoms are an increase in phlegm, a slightly sore throat, a nasty cough and a scratchy voice, not good for teaching. And generally I feel rundown and a little depressed. This morning I visited the doctor for the first time since February. It was a new doctor, as my usual doctor apparently doesn’t work in the mornings. I didn’t want to take any time off work as I’m saving my pennies for an overseas trip, so I was planning to go to work straight afterwards because I didn’t start teaching until 1 o’clock. However the doc put the kibosh on that by giving me a sick certificate for Thursday and Friday, telling me I needed the rest and that I might be infectious. He also prescribed steroids along with the usual antibiotics, in this case Augmentin forte – though I bought the cheapie alternative called Curam Duo Forte – tablets containing a mix of amoxycillin (875mgs) and clavulanic acid (125mgs).
I’m often overly passive and docile with doctors, as with everyone else, and I often don’t clarify my thoughts until after the consultation. So in my usual docile fashion I rang in sick for work straight afterwards, even though this would mean I would lose hundreds of dollars in pay when I could ill-afford it. It’s true that my voice can barely stand the strain at the moment but I enjoy the energy my work gives me. More importantly, I don’t think I’m infectious.
While I recognise of course that our brains often play tricks on us, or more accurately that our brains and our memories aren’t always reliable, that doesn’t always mean that the doctor knows better than we do.
During the consultation the doctor asked me what I thought had caused this latest infection. I said I thought it might be something I ate. He didn’t seem too impressed with that and thought it might be something I picked up from my students, something viral. Hence the idea that I might spread the infection. Here’s the rub though – I actually felt quite certain that it was something I ate, and I know what it was and when it was. And this is not the first time I’ve felt such certainty about one of my many infections. Once it was a glass of wine which gave me a furry tongue, followed by the usual full-blown symptoms, and on other occasions it was food that I’d left a day or so too long in the fridge. These were clearly bacterial not viral infections. On this occasion it was an odd concoction of tabouleh salad, tuna, beans and roast potato that I’d constructed and taken to work for lunch, but had forgotten to eat. I found it later in my bag and scoffed it, half-knowing that I was making a mistake. The first symptoms soon followed.
I wonder how the doctor would have reacted if I’d insisted that it was food and not people that had infected me. It’s not a major issue, but now I also wonder if he’d have given me steroids for a purely bacterial infection. Strangely I didn’t wonder about the steroids until I got home. My neighbour was suspicious of this, saying that steroids were pretty strong stuff. I’ve certainly never had them prescribed for me before and now I wonder why.
According to medicine-net:
Steroids are used to treat a variety of conditions in which the body’s defense system malfunctions and causes tissue damage. Steroids are used as the main treatment for certain inflammatory conditions, such as systemic vasculitis (inflammation of blood vessels) and myositis (inflammation of muscle). They may also be used selectively to treat inflammatory conditions such as rheumatoid arthritis, lupus, Sjögren’s syndrome, or gout.
Bronchiectasis would be classified as an inflammatory condition I suppose, but pertaining to the upper airways, and nothing is mentioned specifically about this. Bronchiectasis is, however, a relatively rare condition (though possibly under-diagnosed). I’ve found a really good, thorough account of the treatment and management of bronchiectasis on medscape, but it says nothing about using steroids. So now I’m just a bit concerned, though I’m sure I’ve been prescribed a low dosage.
Actually on closer inspection I have found a section on medscape, dealing with anti-inflammatory therapy for bronchiectasis, where corticosteroids and other anti-inflammatory drugs crop up. I note that I’ve been given prednisolone tablets by the pharmacist (unfortunately I didn’t check the doctor’s prescription before handing it in, and I wasn’t given it back, so I can’t be sure if this was what the doctor prescribed). Prednisolone, according to Wikipedia, is a corticosteroid commonly prescribed for liver failure, but also used for treating auto-immune conditions such as asthma – so now we’re in the ballpark, so to speak. There are known side-effects for up to 5% of users, but i’ve never suffered any side-effects from any drugs I’ve been prescribed, not that I’ve been prescribed many. And side-effects are more often associated with long-term usage – aren’t they?
Medscape reports the literature on inhaled and oral corticosteroids for use with the many varieties of bronchiectasis and finds it promising but not entirely conclusive. I noted this line in conclusion:
A practical approach is to use tapering oral corticosteroids and antibiotics for acute exacerbations..
It almost seems as if my doctor has memorised this line. I’m feeling a bit more reassured now, but I have no idea what ‘tapering’ oral corticosteroids are. Well, I suppose it’s pretty obvious that it means gradual reduction..
Anyway, here’s hoping for a speedy recovery, and I’ve really got to take more care over food.
A few last words – the doc sent me to Healthscope next door to give a sputum sample, which, astonishingly, is the first time i’ve been asked to give one. The trouble is, if the medication works, I might not revisit the doctor for months, and will never find out the results of the tests on my sputum, just as i haven’t received the result of the blood tests I requested at my last consultation. I wanted to know if my mild anaemia had righted itself, as well as all the other health indicators – HDL and LDL cholesterol, triglycerides, etc. But they never provide you with the results if you don’t persistently ask for them. This is something I might explore further in another post.
exercise is medicine
I read recently that regular moderate exercise sloshes up the blood, washing immune cells from vessel walls. This brings those cells back into the mainstream so to speak, where they can be more effective in combating infection. It makes no small difference – a simple study in which 500 adults were tracked for 12 weeks found that those who engaged in regular aerobic exercise sessions were found to suffer considerably less from upper respiratory tract infections – precisely my personal area of concern. Levels of immune cells in the blood double during exercise.
There’s also good news in this for those of us who couldn’t become gym junkies no matter how hard we tried. Too much exercise (but that means quite a lot) can undo all the good by raising levels of cortisol, noradrenaline and other stress hormones, which alter immune cell functioning. Stress, though, is another one of those complex indicators of health. Mild bouts of stress can be healthful, again boosting blood levels of immune cells. So don’t relax too much, but don’t overdo it.
Even so, exercise helps with everything, and that’s something worth promoting because the recommended dose of exercise isn’t being swallowed by the majority of people in the west. Of course we’ve always kind of known about the benefits of exercise, but the hard evidence has really been coming in lately. A really interesting study was published in the Lancet in 1953, at a time when the rising incidence of heart attacks was becoming a worry. It compared bus conductors to bus drivers on London’s busy double-deckers. The conductors, who spent much of their working day running up and down steps, had half as many heart attacks as their driver colleagues. This landmark study has of course been followed by many others that have confirmed the positive effects of exercise in reducing the incidence of stroke, cancer, diabetes, liver and kidney disease, osteoporosis, dementia and d barkepression.
So what exactly is the goldilocks zone for exercise? Well, anything is better than nothing, and most of us know we’re not doing enough. I’m not quite a senior citizen yet, but studies have been done with the elderly requiring them to do 40 minute walks three times a week, which is hardly strenuous. I catch a tram to work, which requires a ten-minute walk each way, and then a five minute walk each way to my workplace – 30 minutes a day, five days a week, though it would doubtless be better if those 30 minutes were continuous, and if I didn’t dawdle much of the time. The benefits of such a regime have been shown through before-and-after brain imaging. Expansion of the hippocampi, either through the growth of new brain cells, or greater synaptic connectivity, and a restoration of long-distance connections across the brain.
Mental exercise shouldn’t be forgotten either. It has been known for a couple of decades that intellectual stimulation can provide a kind of ‘cognitive reserve’ which can buffer us against the kinds of physical brain deterioration typical of Alzheimer’s and other forms of dementia, but clearer proofs of this have been gathered recently. Magnetic resonance imaging of Alzheimer’s sufferers has caught the goings-on in the brain while cognitive tasks are being performed. Highly educated people – brain workers if you will – are better able to develop alternative neuronal networks to compensate for damaged areas. I would assume though that it’s not so much about education but about brain usage. Keep tackling new things. Keep using your brain in new ways. And your body for that matter.
Cognitive reserve is now seen as a real thing, and has been pinpointed as residing in the dorsolateral prefrontal cortex, a key area for learning, short term memory, attention and language. Increased activity in this area suggests flexibility in thinking and problem solving. Information processing efficiency is also a key to a healthy brain. Having a high IQ, something I’ve often been sceptical about in the past, is an indication of information processing efficiency, even if the information is often culturally specific. It appears that physical brain deterioration, from Alzheimer’s, stroke and and other causes, can be fended off by compensating neural network development and increased information processing efficiency in certain people, until the deterioration becomes too great to be compensated for, after which things tend to go downhill very rapidly. By the time the symptoms of Alzheimer’s appear in such people, the physical damage is already well advanced.
A major message from all this is that you should try to develop lifestyle habits involving physical and mental exercise. Always a work in progress.
I note that one of the in terms these days is ‘hat tip’ (h/t), so h/t for this piece to New Scientist, the collection, edition 3: a guide to a better you.