Time to talk
Orac’s post on the National Center for Complimentary and Alternative Medicine (NCCAM, part of the National Institutes of Health) reminded me of this card [PDF] made by them that I’ve been carrying around in my coat pocket for a while now. It says “Ask” and “Tell” in friendly orange speech bubbles, and it encourages me to speak to my health care provider about CAM treatments. I found it in my doctor’s office, and I wasn’t sure what to make of it.
On the one hand, this card tells me that NCCAM is “[my] source for reliable information about complimentary and alternative medicine.” Reliable is good. I checked out the website for the Time to Talk campaign, which these cards are a part of, and the point of it seems to be that patients should tell their doctors (and doctors should ask their patients) about any CAM treatments they may be pursuing on their own, so that doctors can advise patients about potential health concerns. The patient tip sheet says: “If you are considering a new CAM therapy, ask your health care providers about its safety, effectiveness, and possible interactions with medications (both prescription and nonprescription).”
On the other hand, CAM is still CAM. The best way I’ve ever heard to describe the crux of the issue: “You know what they call ‘alternative medicine’ that’s been proved to work? Medicine.” If NIH’s NCCAM is doing anything other than telling people to get as far away from CAM as possible, they’re doing a deplorable job of promoting public health. From the postcard and the Time to Talk site, it seems like they could be encouraging patients to find out about how pretend acupuncture has the same effects as real acupuncture, or about how homeopathy makes no sense whatsoever. However, as Orac’s breakdown of NCCAM grants makes clear, these are not their priorities. The vast majority of their grant funding is going either to things that shouldn’t be categorized as “alternative” (such as studies of the effects of particular diets on health) or — and this is the real issue — studies of therapies based on truly ridiculous ideas that shouldn’t be getting any credibility from a national research institute. For example: NCCAM funded a study to examine homeopathic succussion (vigorous shaking, claimed to make homeopathic treatments more effective; never mind that shaking doesn’t change the fact they are pure water) and to compare succussion to regular stirring, in order to “improve standardization of homeopathic remedy manufacturing and prescribing.” It’s terrifying to think that real money was spent on this so-called study, and others like it. Orac made the very apt comparison: “it’s like studying whether eye of newt or pixie dust is more efficacious in curing cancer.”
If NCCAM was there to provide an authoritative bank of data showing which supposedly alternative therapies were actually real medicine and which were “alternative” because they were pure garbage, that would be fine with me. I would be very excited about that, to be honest. Unfortunately, no matter how scientific the stated intentions of the center’s directors, they seem dead-set on promoting CAM rather than critically examining it.
Oh, dear
It seems Italy just wrapped up their own version of the Terri Schiavo case. From BBC News:
Eluana Englaro, the Italian woman at the centre of a right-to-die debate, has died, the health minister has said.
Maurizio Sacconi made the announcement in Italy’s Senate as politicians were debating a law that would have forced doctors to continue feeding her.
Ms Englaro, 38, had been in a persistent vegetative state since being injured in a car crash in 1992.
…Ms Englaro’s father, Beppino, had been battling with the courts in Italy to let his daughter die since 1999, insisting it was her wish.
It’s still a sad story. People so obsessed with their own outlook on life that they assume everyone else must share it, and worse that it’s appropriate to legally mandate it. But that’s old news. Rather than rehash it, I’d like to call your attention to this choice bit at the end of the BBC article.
Italy does not allow euthanasia. Patients have a right to refuse treatment, but they are not allowed to give advance directions on the treatment they wish to receive if they become unconscious.
Are. You. Kidding. Me. They agree with the principle that patients should be legally able to refuse treatment. They’re just not okay with allowing those patients to put that refusal down on paper, to remove ambiguity. In other words, patients have the right to refuse treatment, except for the vast majority of cases in which patients might want to refuse treatment.
Oh, dear.
Mandatory ultrasounds
Via blog.bioethics.net: 11 state legislatures are facing proposed legislation to offer or require women seeking abortions to see ultrasound images of the fetus, and in some cases listen to the heartbeat. Lest you be confused, these are women who have, in at least the vast majority of cases, already decided to have an abortion. Some of these proposals allow the ultrasound to be done right up to 30 minutes before the abortion procedure. Several of the states graciously allow an 18 or 24 hour waiting period. (The AP story lists 12 states in total, but one in their list is actually South Carolina’s extension of an existing 1-hour law to a 24-hour one. Very sweet of them.)
The goal of these proposals is obviously, in Dr. Johnson’s words, “that [the woman] might catch a glimpse of her unborn fetus and change her mind.” If only they knew it had a heartbeat! pro-life legislators are musing. They assume that women getting abortions are doing so on a whim and have never really thought about the implications. This is insulting. It’s obviously a terribly difficult decision which every woman facing it agonizes over. Admittedly there is the occasional irresponsible person, but the real effect of any of these laws passing would be to put thousands of women through intense psychological trauma, on top of what is already an emotionally taxing experience.
Unable to actually ban abortion outright, these lawmakers are erecting bizarre barriers around the procedure to serve as criminal sentences. Their intentions are plainly to punish women, but they do so in a cruel and scarring way and under the perverse pretext of medical regulation. If abortion is not illegal, we shouldn’t be punishing the act.
I know random and strange legislation gets proposed all the time without any real hope of passing. However, the fact that this has popped up in a dozen states at once makes me worry that there’s some real initiative behind this horrible idea. I hope the other legislators step it up and vote it down.
New York’s soft drink tax
Last month, New York Governor David Paterson proposed adding an 18% statewide tax to non-diet sodas and sugary juice drinks. Though it does have some supporters, the plan has drawn plenty of criticism from nutritionists as well as small-government proponents. Fox News is even getting their fair and balanced panties in a twist about it. Despite all the criticism, I think it’s a great idea.
I know that nobody likes taxes. At the same time, though, most people like police and fire departments that are operational, public schools that can afford textbooks, and courthouses that can handle enough trials. The government needs to collect some tax revenue. The real question is, where should we take taxes from?
Every time the government taxes something, it changes the incentives for doing that thing. Income taxes make working less valuable, because they lower the wages you receive. Sales taxes discourage making purchases. Property taxes discourage owning property. (All these things are really only visible at the margins. Imagine that you have five dollars in your pocket and you want to buy a sandwich that costs $4.95. After sales tax, you can’t afford it anymore. Now, instead of thinking about how much cash you have on you right now, think of it in terms of a long-term budget, and you’ll get the idea.) If we want people in society doing a certain thing, or we want to make sure they are able to, we should keep taxes low on it. That’s why many places don’t tax groceries; they’re a necessity of life. Inversely, if we want people to stop doing something, we ought to tax it as high as is feasible. That’s why cigarette taxes exist, and why there should be a higher tax on gasoline. Taxes allow consumers to consider the externalities of their behavior. The tax is like adding on the social cost of people’s behavior, spread out over each individual act of consumption.
It’s bad that so many Americans are obese. According to Governor Paterson, nearly one in four New Yorkers fits that description. This puts a burden on New York’s medical resources, both in terms of time and space and in terms of funds available for government healthcare assistance. Therefore, it makes sense for New York to disincentivize obesity. They’re not locking people up in prison for it. Just making it a little less appealing.
If a tax can be used to achieve some social good like this, it means other taxes can remain lower (or can be lowered, depending on the current state of things). It seems to me that it’s a win-win situation. Better health in society, better allocation of taxes. Some people (like our friends at Fox News) think that this is cynical and hypocritical. Steven Milloy writes, “Combating obesity is not grounds for the tax; it is, instead, camouflage for it — and not very good camouflage at that.” This is a serious mischaracterization. What happens is, either New Yorkers drastically reduce their soft drink intake, which is a good thing, or New York makes a bunch of its tax revenue off a negative behavior rather than a positive one like working or buying groceries, which is also a good thing. No one is camouflaging anything.
Now, some of the criticism has been more along the lines of, “This isn’t enough.” It’s true that reducing the amount of soda you drink won’t instantly put you at your ideal weight. There are other types of food that are bad for you. Exercise still matters. However, this sounds to me like arguing that if you have anvils crushing both your feet, it’s not worth it to try to move the one on the right. Doing something in this case is still helpful, even though it isn’t everything.
Not evaluated by the FDA
Due to some scheduling freedom, I’ve lately become a bit nocturnal, and I’ve found myself watching a lot of late-night/early-morning TV. This has given me the opportunity to reflect on the ridiculous ads that companies save until we are maximally sleep-deprived and hopefully stupid enough to believe the crap that they are shoveling. Frankly, it is unbelievable.
I wanted to write something all about Dr. Frank’s No Pain Spray, because I’ve seen about nine zillion commercials for that. But once you get over the fact that it’s an oral spray that looks like a breath freshener but that’s supposed to provide all the way up to post-surgery level pain relief (no, I’ll take the Percocet, please), the fact that it claims not one but ten different homeopathic ingredients (slightly increasing the probability that a single non-water molecule might exist in the spray), and the fact that it’s only advertised at 3 AM (not a good sign for credibility), there’s really not a lot more to mock. Borrr-ing. Besides, someone else has done it more thoroughly than I would care to.
However, I think it’s important to say something about a more general problem I have with this class of advertisements. All these diet pills, “male enhancement” tablets, and so on make their claims of widespread success, then display the tiny text: “This product has not been evaluated by the FDA.” Is that enough to meet our legal standard for truth in advertising?
The Federal Trade Commission has this very clear FAQ about false advertising on their website. In particular I think it’s worth highlighting this one.
What makes an advertisement deceptive?
According to the FTC’s Deception Policy Statement, an ad is deceptive if it contains a statement – or omits information – that:— Is likely to mislead consumers acting reasonably under the circumstances; and
— Is “material” – that is, important to a consumer’s decision to buy or use the product.
It goes on to explain the process the FTC uses to investigate claims of false advertising, and uses the particular example of a mouthwash that claims to prevent colds. The FTC looks from the point of view of a “reasonable consumer” and evaluates both “express and implied claims,” checking to see if the advertiser has enough proof to back them up. In the particular example of medical or other scientific claims, the advertiser is expected to have “competent and reliable scientific evidence.”
I also found a page on the FTC’s website called Dietary Supplements: An Advertising Guide for Industry. It has a lot of important and relevant information, and in particular in section II.C.3 mentions the Dietary Supplement Health and Education Act (DSHEA) disclaimer, “that the statement has not been evaluated by FDA and that the product is not intended to ‘diagnose, treat, cure or prevent any disease.’” DSHEA doesn’t explicitly apply to advertisements, but this document does say that it’s a good idea to include the disclaimer “to prevent consumers from being misled about the nature of the product and the extent to which its efficacy and safety have been reviewed by regulatory authorities.” I was glad to see this example used to illustrate the issue:
Example 34: An advertisement for an herbal supplement includes strong, unqualified claims that the product will effectively treat or prevent diabetes, heart disease, and various circulatory ailments. The advertiser does not have adequate substantiation for this claim, but includes the DSHEA disclaimer prominently in the ad. In face of the strong contradictory message in the ad, the inclusion of the DSHEA disclaimer is not likely to negate the explicit disease claims made in the ad, and will not cure the fact that the claims are not substantiated.
This is a good standard to have. There are two prongs to the DSHEA disclaimer; I’ve usually only seen the first half used (in small and hard-to-read print, no less). The second half, that the product is not intended to provide any actual medical service, would seem ridiculous when compared to the explicit claims of medical service made over and over again in the ad. Of course it’s intended to diagnose, treat, prevent, or cure something! The first half of the disclaimer, though, is even less effective at offsetting the false advertising. The lies may not have been evaluated by a regulatory agency, but that doesn’t make it okay to lie. It’s the advertiser’s job to make sure what’s in the ads is true, and this feeble attempt to displace blame is laughable.
The problem, then, is not that we don’t have a good standard delineating what’s false advertising, bur rather that the standard is not being enforced. These advertisements aren’t just stupid, they’re nefarious — they’re lies told only when viewers are expected to be at their weakest emotionally and blurriest rationally.The FTC needs to step it up and get these cranks off the air.
“Natural” isn’t always better
The New York Times recently ran a story about how best to prepare vegetables. It turns out that raw foods and vegetables aren’t necessarily better for you than they would be if you cooked them — and sometimes they’re worse. Tara Parker-Pope writes:
The amount and type of nutrients that eventually end up in the vegetables are affected by a number of factors before they reach the plate, including where and how they were grown, processed and stored before being bought. Then, it’s up to you. No single cooking or preparation method is best. Water-soluble nutrients like vitamins C and B and a group of nutrients called polyphenolics are often lost in processing. …
Fat-soluble compounds like vitamins A, D, E and K and the antioxidant compounds called carotenoids are less likely to leach out in water. Cooking also breaks down the thick cell walls of plants, releasing the contents for the body to use. That is why processed tomato products have higher lycopene content than fresh tomatoes.
In January, a report in The Journal of Agriculture and Food Chemistry concluded that over all, boiling was better for carrots, zucchini and broccoli than steaming, frying or serving them raw. Frying was by far the worst.
Surely it’s a good idea to make an effort to include some raw vegetables in our daily consumption. It’s interesting to note, though, that the conventional wisdom that raw is better is not true in all cases. Some people, however, take that supposed wisdom to an unhealthy extreme. The “raw food diet”, typically also vegan, is about the strictest interpretation of all-natural eating. As this About.com summary explains, followers of this diet avoid eating anything heated to over 116° F (47° C).
On face it seems a little silly to me that in the search for the most supposedly natural lifestyle, some people have chosen to go back to before the discovery of fire. But then, even About.com has filed this article in the alternative medicine category, along with articles about acupuncture (equally effective when you’re pretending to do it) and homeopathic remedies (which are based in part upon the premise that diluting something makes it more potent).
Of course, even those of us who don’t follow extreme diets like this one fall prey to this simplistic sort of thinking all the time. Grocery stores can charge higher prices for organic food because so many of us assume that if it’s organic it must be worth the extra cost. And sure, pesticides and other chemicals used on food can be dangerous in large quantities, but worm-filled or mold-covered food isn’t exactly healthy either. (I’m reminded of the Vital Signs podcast from last February that described the case of an infant who contracted botulism from some natural honey.) The healthiest lifestyle is actually a happy medium between limiting the “unnatural” chemicals we consume and avoiding the all-too-natural ways of getting sick.
I believe this highlights a major fallacy in the popular conception of health: that things are better for you if they’re more natural. First of all, “natural” isn’t even an adjective that can be clearly defined, given that we can’t exactly return to some sort of Hobbesian state of nature to look around and take notes. But also, many things commonly viewed as “unnatural” such as technological and chemical advances have actually vastly improved our lives. I’m happy to live in a world with telephones, penicillin, electricity, printing presses, the wheel… and I’m also glad we have pasteurized and vitamin-fortified milk, irradiated meat, and rice genetically modified to have 20 times the beta carotene.
At the end of the day, I think we just have to remember that the story is always more complicated than it seems at first. It’s appealing to think there are clear cut rules for how to live the healthiest life, but following a rule like “natural equals good for you” can actually be detrimental to your health. A little bit of critical thinking can go a long way.
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