Junkfood Science: December 2008

December 31, 2008

“Fat is catching” theory exposed

The social networking theory of obesity was skillfully debunked in this month’s issue of the British Medical Journal.

This theory first made the news last year with the release of a paper by Nicholas A. Christakis, M.D., Ph.D., MPH, a medical sociologist from Harvard Medical School, and James H. Fowler, Ph.D., political scientist from the University of California, San Diego. Their study was reported to have shown that you can “catch” obesity from having fat friends and that obesity is so contagious, it can be spread long-distance by email and instant messaging. Even healthcare professionals, who didn’t understand the etiology of true obesity or how statistics can be misused, failed to detect the implausibility of “second-hand obesity.” In fact, some doctors became so enamored with the new “science of networking” they believed it should be a new medical specialty: network medicine.

It’s been long understood that fears, beliefs and ideologies spread among people and social contacts. That’s the core to sales and marketing. There’s no need for a special theory to explain that! And, of course, communicable diseases can spread through contacts. But the notion that you can “catch” a physical trait — like chin dimples or obesity — or a health condition, like diabetes or cancer, from the people you associate with is implausible.

Professors Christakis and Fowler couldn’t give a biologically plausible explanation for their finding that long-distance friendships were more associated with obesity than immediate friends and neighbors, marriage partners, or living with a fat person. However, attempts to point out the flawed methodology used in that study, or to illustrate the fallacies of logic behind it, were called absurd and couldn’t break through the quick popular acceptance of this theory. It seemed to confirm what everyone “knew” — that obesity was spreading like an epidemic and all because of socially undesirable behaviors and attitudes. And obesity interests embraced the “profound policy implications of the study,” as it supported social change to address the obesity epidemic among entire groups of people and whole communities.

A social networking theory of contagious chin dimples might have been understood as implausible, but not so of obesity. While scientists have recognized for more than half a century that “the heritability of obesity is equivalent to that of height and greater than that of almost every other condition that has been studied,” as Dr. Jeffrey Friedman, head of the Laboratory of Molecular Genetics at Rockefeller University in New York, has explained, the science hasn’t broken through the simplistic notion that weight can be controlled proper diet and behavior.

Two researchers prove the flaw

Recognizing the implausibility of the social networking theory of obesity — as well as social networking increasingly being used to explain other implausibly related physical traits and conditions — Jason M. Fletcher, Ph.D., assistant professor at the Yale School of Public Health in New Haven, Connecticut, along with Boston economist, Ethan Cohen-Cole, Ph.D., designed an ingenious study. They selected conditions that no one would seriously believe were spread by social networking and online friendships: height, headaches and acne. They then applied the same standard statistical methods used in Christakis and Fowler’s social networking research to “find” that acne, height and headaches have the same “social network effect.”

Many methods used to estimate social network effects are subject to potentially large biases that result in the increased likelihood of detecting social network effects where none exists. For example, the use of standard econometric methods from literature on peer effects substantially reduces evidence of social network effects in obesity.

As they explained, patterns of association among people can lead to correlations in health conditions between friends that are not caused by direct social network effects at all. The problem of confounding factors plague correlations. For example, people usually choose to become friends with someone who is very similar to themselves. It is also commonly assumed that the variables a researcher selected to control for are the appropriate ones to isolate true network effects. If these problems are neglected, they wrote, “one can improperly interpret the results to imply that true ‘network effects’ exist.”

Noting bias in previous social networking research, the three health outcomes they examined (pimples, headaches and height) could not credibly be caused by social networking, they said. They used the National Longitudinal Study of Adolescent Health (Add Health) database of 4,300 and 5,400 male and female teens, which had followed the teens and their friendships over three waves from 1994 to 2002.

Using the methods common in recent medical literature for detecting “social network effects,” they found effects could be produced where none actually existed. The correlations were actually untenable [“fragile”], but large enough that they would popularly not be rejected as null, even though the true contagion effect is null.

They found increased relative risks of 58% for height, 62% for pimples, and 47% for headaches associated with the social network effect. These are similar, they said, to the 57% increased relative risk for obesity when a friend is obese and the 36% increased relative risk in quitting smoking when a friend quits that had been reported by Christakis and Fowler in their published social networking studies.

“Even truly implausible effects can generate results that support the hypothesis,” they said, and be used to generate premature claims of social network effects.

There is a need for caution when attributing causality to correlations in health outcomes between friends using non-experimental data. Confounding is only one of many empirical challenges to estimating social network effects.

You cannot “catch” fat from associating with a fat person anymore than you can catch tall from having a tall friend. There is no credible evidence.

© 2008 Sandy Szwarc

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December 30, 2008

Living longer with resveratrol — a different perspective

Has the secret of the Fountain of Youth been discovered? Is it really possible to reset our biological clocks and protect ourselves from the aging process? Can a miracle pill cure all the major killers of aging, including diabetes, heart disease and Alzheimer’s, and add 30 healthy years to our life?

Live To Be 150 … Can You Do It? Barbara Walters breathlessly reported on her ABC anti-aging special on April 1st, that Dr. David Sinclair says he’s found the genetic key of longevity in mice, as well as a molecule that turns the gene on so that people in their 80s could live like they’re in their 50s. Resveratrol, as found in red wine...about a thousand bottles a day. “Some would say you’re raising expectations that can’t possibly happen,” she asked him in her interview.

“But it’s true,” said Dr. Sinclair. “What can I say? If we cure the major killers of Western society, people will live longer, healthier lives.”

Ms Walters’ reported that he’d teamed up with Dr. Christoph Westphal and together they’d raised $100 million for research. If all goes well with the clinical trials on type 2 diabetes, Dr. Westphal said, they’ll seek FDA approval in the next five years.

Resveratrol — making news for years

Dr. David Sinclair, Ph.D., associate professor of Pathology and Co-Director of the Paul F. Glenn Laboratories for the Biological Mechanisms of Aging at Harvard Medical School in Boston, is the name behind resveratrol research. He’s been featured in media for years — including Forbes, Fortune, Scientific American, Wall Street Journal, Newsweek, Charlie Rose and Barbara Walters — making similar anti-aging claims of the antioxidant resveratrol, as found in red wine.

Dr. Sinclair was also featured on a video made for the multi-level marketing dietary supplement company, Shaklee Corporation, as a member of its Scientific Advisory Board. Shaklee sells Vivix Cellular Anti-aging Tonic, which is advertised as a blend of polyphenols with resveratrol in an amount equivalent to 3,000 glasses of red wine. There seems to be nothing this miraculous tonic and “revolutionary breakthrough” isn’t claimed to do. Each health benefit claim, according to Shaklee, is based on more than two thousand published studies.

In the Shaklee video, Dr. Sinclair said that resveratrol molecules have worked in every organism they’ve fed them to, turning on the pathway that repairs DNA cellular damage to slow the aging process. By concentrating resveratrol, made by plants to protect themselves from stress, we can get the same natural benefits, he said, and it could potentially have a big impact on aging and the major degenerative diseases.

“We have the technology now to make molecules, consumer products and drugs that can give you the benefits of diet and exercise without actually having to do those things,” he said. He added that he is interested in the whole polyphenyl family of compounds and the health benefits they can impart, singly or preferably in combination, with resveratrol. “When you turn on the body’s natural defenses, you might expect remarkable things and that’s what we’re seeing in the clinic and in human trials against diabetes and hopefully, soon, in many others,” he said. We may find a group of people living longer. “Hopefully, I’m one of them,” he said, saying that he believes in resveratrol so much he’s taken it for years.

With Dr. Christoph Westphal, M.D., Ph.D., he founded Sirtris Pharmaceuticals to develop anti-aging drugs. Dr. Sinclair now co-chairs its Scientific Advisory Board while Dr. Westphal serves as Chief Executive Officer. Sirtris was bought by GlaxoSmithKline earlier this year for $720 million, in a deal that reportedly earned Dr. Sinclair more than $8 million and $297,000 a year in consultant fees.

Amidst all of this excited media coverage, the public heard little to nothing about what the body of scientific research actually showed or the red flags of concern and cautionary warnings.

Another news story — conflicts of interest

This past week, Dr. Sinclair made the news in a different way when the Wall Street Journal reported that he’d resigned from his paid position on the Scientific Advisory Board of Shaklee. According to the WSJ story, Dr. Sinclair “now says his name has been misused in connection with Vivix,” in ways that imply he endorsed Vivix. He has demanded that Shaklee cease using his name.

Note that Dr. Sinclair wasn’t admitting that he may have been overstating the research to imply endorsement for resveratrol supplements, only that his statements were being used to imply an endorsement for Shaklee’s resveratrol supplement.

WSJ also reported that Harvard has been reviewing Dr. Sinclair’s connection with Shaklee and that Sirtris Pharmaceuticals-GSK was working on its own resveratrol drug for diabetes. In a statement, according to WSJ: “Shaklee said that ‘every implied product endorsement was in Dr. Sinclair's own words and every Shaklee use of his name — whether in print or video — was pre-approved by him in keeping with our agreement.’”

Dr. Sinclair’s assertion took the biggest beating in the video WSJ posted on its website. It showed Dr. Sinclair speaking at the Shaklee sales meeting this past August, saying to the sales people:

Over a year ago, we set out together to do this, to make a product that you could actually activate these genetic pathways that can slow down aging. Together, as part of the Shaklee family…we can take this technology right now, to our friends, to our family, and really have the benefits of this new technology right now, within our lifetimes.

This news story has fueled debates over financial disclosures among researchers. The concerns over potential conflicts of interest haven’t focused so much on the funding for research. We can’t automatically assume that research funding means an investigator is guilty of misconduct. That would be falling for the ad hominum fallacy of logic and neglecting the fact that money for research has to come from somewhere. It’s also easy to forget that all sources can potentially impart bias and that government and nonprofit grants can come with as many strings to conform to agendas, as those from industry.

What makes this situation different is that it calls to question whether the integrity of science is compromised when researchers accept money to endorse products, and allow their names and universities to be used in product marketing, especially when the products are the very ones they are researching. Are many researchers able to remain objective when they have significant interests in the outcomes of the research — more specifically, maintain objectivity when interpreting and reporting the findings? Or, is the urge to overstate the favorable evidence and downplay the limitations too great?

Only the science itself can help us answer those questions.*

The landmark resveratrol research

There’s a reason resveratrol studies haven’t been reviewed at JFS to date. Only clinical trials on people offer information we can use, but there have been no randomized controlled clinical trials of resveratrol on humans published. [Regular readers will remember only two exceptions to reporting only human research: a study on a worm and one on zebra finch.]

Nor has the research to date provided anything of direct benefit to the public. While people aren’t lab rats, even the mice studies have yet to find credible support for claims surrounding resveratrol. And you are certainly not a yeast cell, worm, fly or fish! Studies done in a test tube on yeast cells, worms, flies, fish, mice and other species are preliminary investigations and have a long way to go before they’re ready for prime time. But even those done on resveratrol to date have been controversial.

Reporting on laboratory research, as scientists explore various theories and hit endless dead ends before finding one that might have potential, is of interest to chemists and biologists, but not much help to the general public. Lab research is years from becoming clinically-proven treatments for us. Once out of the lab, there’s still years of clinical trials on humans — phase I, phase II and phase III clinical trials — each to answer different and important questions. [Covered here.]

A search of Clinicaltrial.gov, where clinical trials are registered, found no registered trial on resveratrol for diabetes or aging led by Drs. Sinclair or Westphal, conducted at Harvard, or funded by Sirtris. In other words, seeking FDA approval to market a resveratrol drug to prevent diabetes, Alzheimer’s, heart disease or cancers, let alone extend lifespans, isn’t going to be happening anytime soon, despite what we’ve been hearing.

But the media didn’t wait for clinical trials. In November 2006, a mouse study by Dr. Sinclair and colleagues was published in Nature. It reportedly demonstrated resveratrol was the anti-aging secret and can extend life. This is the landmark resveratrol study that has made the news for more than two years ever since.

Resveratrol, like antioxidants, has been chic, all the rage, popular and newsworthy. No one has stopped to read the study and notice that it didn’t actually find what it was being claimed to have found. Nor, has anyone reported that, to this day, it has yet to be independently replicated.

Briefly, at one year of age, an unknown number of male mice were fed their standard diet or a high-calorie diet along with resveratrol at two concentrations. After six months, there was a “clear trend towards increased survival and insulin sensitivity at the high dose,” the Harvard authors wrote in the introduction, so the study was continued only at the higher dose. At the end of the 114-week study period, they reported that 42% of the high calorie diet with resveratrol group had died and 42% of the standard diet control group had died. As the authors wrote in their conclusion: “We cannot yet confidently predict the ultimate mean lifespan extension.”

In other words, this study didn’t test two groups of mice similarly eating ad lib, with the only difference being the resveratrol given one group. It did not actually show resveratrol itself extended lifespan.

These mice live an average of 2.5 years (130 months), yet the authors didn’t report what happened as the mice reached old age. Did they even live out their life expectancy, let alone longer? Instead, the claim of a statistical 30% benefit came only when the mice were compared to mice that were force-fed unnaturally high calorie diets of 60% fat — a diet that bears no resemblance to what humans eat and is nearly twice the fat that even Americans eating a fatty Western diet consume. Nor could any comparisons be made to credibly suggest anything about fat people because as a group they eat no differently than naturally thin people.

This year, the Harvard group published a study that better isolated resveratrol’s effect, from extreme dietary manipulations. In a press release on July 3, 2008, Sirtris Pharmaceutical reported that it had found that resveratrol [a polyphenolic SIRT1 activator] mimics calorie restriction in mice and may extend life by inducing similar pathways in mitochondrial gene expression in vivo. The study behind that press release, led by Dr. Sinclair, was published in the August 6th print edition of Cell Metabolism. It turned out, however, to have actually reported that resveratrol induced gene expression patterns in some tissues similar to caloric-restricted mice without extending lifespan. Mice “fed a standard diet did not live longer when treated with resveratrol. Our findings indicate that resveratrol treatment does not increase the longevity of ad-libitrum-fed animals when started midlife,” the researchers concluded. Resveratrol failed to actually help the mice live longer.

Also in that July issue of Cell Metabolism, Dr. Matt Kaeberlein, with the Department of Pathology at the University of Washington, Seattle, Washington, wrote about the “ongoing saga of sirtuins and aging,” saying that “sirtuins are known to slow aging in simple eukaryotes,” however in mammals, viewing sirtuins as antiaging proteins may be overly simplistic. As he explained, evidence in the same issue of Cell Metabolism showed “that SIRT1 has properties consistent with both pro- and antiaging functions in mice.” In other words, it appears resveratrol may also increase aging.

This is reminiscent of the popular misunderstandings surrounding antioxidants and the free radical theory, and why antioxidants continue to not prove to have special benefits in human studies, and in some cases suggest harmful effects. Many antioxidants are really redox agents (antioxidants in some instances and working as pro-oxidants in others, actually producing more free radicals) and could increase risks for things like cancer. Especially at larger doses, researchers have also cautioned that antioxidants can alter a number of body functions, hormones, metabolism and absorption of minerals. [Covered here.]

Cause to pause — cautionary notes

Before going on, it might be helpful to get some background information on resveratrol and sirtuins and the body of evidence. A family of genes that makes proteins called sirtuins have been theorized as playing a role in mitochondria (the energy centers of cells) and to correlate to genes activated during caloric restriction in animal studies. Among the molecules that can activate the sirtuin genes is a resveratrol-like compound that acts on the SIRT1 gene. Actually, they don’t know exactly what the pathway involved may be, as they’ve used a proxy measure of SIRT1 activity to show a correlation between the more active enzyme and mice treated with resveratrol.

Resveratrol is produced when plants are stressed, as a survival response. The resveratrol used in these studies, however, isn’t at the amounts found in nature. That’s because, as Dr. Westphal has said, native resveratrol isn’t effectively absorbed in our gut and can’t reach the bloodstream. We’d also have to take hundreds a day of the “resveratrol dietary supplements” being sold to reach the levels being researched in these studies.

More precisely, as research led by Dr. Thomas Walle, Ph.D., at the department of cell and molecular pharmacology and experimental therapeutics at MUSC in Charleston, South Carolina, has reported, the benefits attributed to dietary resveratrol are based on laboratory modeling. However, it’s not clear whether the drug even reaches the areas where it’s said to act, especially in humans. They found in a brave group of human volunteers that only trace amounts of resveratrol could be detected in the blood stream after it was ingested. Most of it was just excreted in the urine. While resveratrol had low bioavailability, it isn’t known if it might potentially accumulate anywhere in the body and produce long term effects or what those effects might be.

The mouse study by Dr. Sinclair’s group, published in the 2006 issue of Nature, that set the media ablaze, came with a press release. The public has heard little to nothing about the caveats noted in a review article on resveratrol research that was published in the same issue. This paper was written by biology of aging researchers Dr. Matt Kaeberlein, Ph.D., the primary investigator at Kaeberlein Lab at the University of Washington Medical Center in Seattle; and Dr. Peter S. Rabinovitch, M.D., Ph.D., professor of pathology, Joint Full Member of the Fred Hutchinson Cancer Research Center, and Director of the Nathan Shock Center of Excellence in the Basic Biology of Aging at the University of Washington.

Resveratrol’s role in aging first became of particular interest to gerontologists, they said, with a letter published in the 2003 issue Nature that reported discovering three molecules that can activate sirtuins. It was written by Dr. Sinclair and colleagues and claimed that resveratrol could increase lifespan in yeast 70% by activating particular enzymes (protein deacetylases) of the SIR2 family of proteins (sirtuins).

However, said Drs. Kaeberlein and Rabinovitch, the results from that first yeast study have remained controversial and other researchers have been unable to replicate its findings. Their own research, published in the Journal of Biological Chemistry in 2005, found “resveratrol has no detectable effect on SIR2 activity in vivo, as measured by rDNA recombination, transcriptional silencing near telomeres, and life span.” They concluded: “In light of these findings, the mechanism accounting for putative longevity effects of resveratrol should be reexamined.”

“Subsequent work has suggested that resveratrol has modest effects on lifespan in both worms and flies, and a more substantial effect on lifespan in a short-lived fish,” they wrote in their 2006 Nature review. The source of the suggestion of possible effects on lifespan in worms and flies was a letter published in a 2004 issue Nature by Dr. Sinclair and colleagues, based on tests on Caenorhabditis elegans and Drosophila melanogaster.

The source for suggestions of an effect on the lifespan of fish, according to Drs. Kaeberlein and Rabinovitch, was a small study done on a rare species (Nothobranchius furzeri) found in southeastern Africa. This species is an evolutionary oddity and has the shortest known lifespan (12-13 weeks in captivity) of any vertebrates on the planet. In this study, researchers at Scuola Normale Superiore in Pisa, Italy, fed 110 fish resveratrol in three different concentrations and reported a correlation to genetic expressions of aging biomarkers at a cellular level found in these vertebrates and prolonged lifespan at the highest doses (and shortened life at the lowest dose). Resveratrol was associated with delayed decay of locomotor activity and cognitive performances and reduced expression of neurofibrillary degeneration in the brain, they said. But, the Italian researchers urged caution. The mortality trajectories in these fish were like those seen when the water temperature is reduced, they said, not like those seen in caloric restriction. They also “observed that resveratrol induced an early increase in death rate after administration.”

Based on these findings,” said Drs. Kaeberlein and Rabinovitch, “it has been proposed that resveratrol increases lifespan in several different organisms by a mechanism similar to dietary restriction.”

The source of this proposal was a 2006 Nature review article written by Dr. Sinclair and colleague Joseph Baur at Harvard. At that time, their November 2006 mice study hadn’t yet been published. “Despite scepticism concerning its bioavailability, a growing body of in vivo evidence indicates that resveratrol has protective effects in rodent models of stress and disease,” wrote Drs. Sinclair and Baur. This data was the basis for their conclusions of resveratrol’s “potential as a therapeutic for humans.”

Drs. Kaeberlein and Rabinovitch said that while Dr. Sinclair’s group “favor the view that many (perhaps all) of the beneficial properties of resveratrol are the result of increased sirtuin activity, and various studies have supported the idea that sirtuins underlie the effects attributed to resveratrol in vivo… there is a surprising lack of biochemical evidence that resveratrol directly increases sirtuin-mediated deacetylation of biologically relevant substrates, and some evidence that it may not. Resveratrol is also known to interact with numerous proteins and pathways…” Resveratrol is not the last hope of gerontologist or even the best, they wrote.

Did you pick up the red flags? It’s not like this is an obscure field of medical research and that virtually every pharmaceutical company in the world isn’t looking for an anti-aging drug and cure for diabetes and other diseases of old age! When extraordinary claims that overstate the quality of the evidence come from one source, let alone from Harvard, and haven’t been independently replicated, that’s a red flag of caution before buying it.

Should you start popping resveratrol?

Not only have two dubious studies done in 2006 — one on mice and one on vertebrae — been all the evidence the media’s needed to produce years of sensational stories, they’ve also been all that a massive and thriving business of online companies have needed to market resveratrol dietary supplements, with promises of life extension benefits for humans.

Unthinkably, the same consumers who would probably be horrified by a harmless chemical found in parts per billion in their food are rushing to ingest a chemical produced in a laboratory at 3,000 times greater concentrations than found in foods and believe it will improve their health. And spend $100/month to boot.

Similarly, few people would be in favor of the FDA approving drugs, especially for healthy people to take for life, that haven’t been clinically shown to be safe and effective. Yet, dietary supplements are able to bypass the requirement for clinical evidence.

Before popping those resveratrol supplements on the market, it’s important to know that there are no standards for the methods various manufacturers use to isolate resveratrol. It’s no safer than experimenting with any other new manmade chemical developed in a laboratory. Since dietary supplements aren’t regulated by the FDA, there are no quality standards, nor have any of the supplement makers published data on the variability between their different lots in the amounts of resveratrol they contain.

No one knows what dose in humans is safe, effective or what the risks of taking them for years might be, such as developing cancer. None of the resveratrol supplements have published toxicology tests and there is no information on how they might interact with other drugs. Given the unknowns and lack of clinical research on humans, benefits that are speculative at best, and reasons to indicate potential risks for harm (especially given what has been learned about other antioxidants at high doses), no credible medical professional would recommend anyone begin a life-long resveratrol supplement regimen.

Drs. Kaeberlein and Rabinovitch had similar concerns. To anyone wondering if they should start supplementing their diets with resveratrol, they wrote: “Our advice is to exercise caution.” The safety of resveratrol at the high doses being tested is unknown, especially taken over years or even decades. “Even modest side effects could have dramatic consequences,” they wrote. “For now, we counsel patience. Just sit back and relax with a glass of red wine…”

© 2008 Sandy Szwarc

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* Even without getting into the scientific research itself, all of the clues are there to help us figure out if these claims of benefits for humans are credible. Falling back on those basic tenets for protecting ourselves against health fraud and fake remedies make a surprisingly good place to start.

As covered here, to evaluate any new modality, there are some simple things that can also help us know if something is sound. To start:

● if it’s been tested in phase III, human clinical trials that are well-designed to be fair tests, and clearly shown to be safe and effective, based on objectively-measured hard clinical outcomes, rather than false surrogate endpoints;

● if its potential benefits outweigh the risks;

● if the research has been independently replicated and holds up to the body of evidence and biological plausibility;

● and if the research has been published in peer-reviewed scientific literature.

What doesn’t matter is many people agree, how prestigious or famous the person is who’s selling the remedy, how many amazing testimonials or before-and-after pictures we’re shown, how much news coverage it gets, how polished the product literature or website looks, or how impressive the accompanying bibliography.

Interventions that claim to slow aging or prevent diseases associated with old age — such as cancers, heart disease, diabetes or dementia — have long been a source for spurious modalities. One of the most popularly believed adages is that lots of antioxidants can avert free radical damage and prevent chronic diseases and enable us to live longer. Decades of randomized, placebo-controlled clinical trials, however, have failed to support such abilities of antioxidants — or any dietary factor. People around the world have enjoyed a wide range of diets with no common relationship to lifespans or health. Even the recent Cochrane Systematic Review of every clinical antioxidant trial conducted since 1945 found not a single one had been able to find a tenable effect. [Covered here.]

Humans have been trying to find the secret to longer life throughout recorded history, and countless people have claimed to have found it. But haven’t. Fifty-one of the world’s most recognized scientists in the field of human aging, concerned about the continued quackery surrounding aging, recently examined the scientific research and published their findings in Scientific American and the Journal of Gerontology: Biological Sciences and is available online here. Their concluding remarks said:

Since recorded history individuals have been, and are continuing to be, victimized by promises of extended youth or increased longevity by using unproven methods that allegedly slow, stop or reverse aging. Our language on this matter must be unambiguous: there are no lifestyle changes, surgical procedures, vitamins, antioxidants, hormones or techniques of genetic engineering available today that have been demonstrated to influence the processes of aging.

The next anti-aging remedy that comes along will, no doubt, claim to be different and be the miracle breakthrough. It will probably be endorsed by highly degreed professionals from prestigious institutions who say they know they’ve finally found the secret. Look for the clues.

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A life-saving business

It can be easy to forget that healthcare is big business and can be as much about financial and political interests as it is the practice of sound medicine. This is especially the case with Public Health. A group of doctors and scientists concerned about the failure of the government Department of Health to adhere to evidence-based medicine, and believing patients benefit from the best treatments available, got together and asked for support from health executives across the country…

They wrote the chief executives of 467 NHS Trusts and what happened next demonstrated that public health officials don’t make decisions about what treatments and research to fund based on what works or makes fiscal good sense. Their letter urged the government not to squander limited healthcare resources on unproven and disproved treatments that are costing quite a lot of money — money that the NHS needed to be spending on things that work.

As Dr. David Colquhoun, professor of pharmacology at University College London, writes today at DCScience, it seemed like such a simple and self-evident idea. But…

It turns out that quite a lot of patients are deeply attached to unproven and disproved treatments. They clamour for them and, since “patient choice” is high on the agenda at the moment, they quite often get them… The government often says that it takes the best scientific advice, but the DoH seems to have something of a blank spot when it comes to alternative medicine. Nobody knows why. Perhaps it is the dire lack of anyone with a scientific education in government. Or could there be something in the rumour that the DoH lives in terror of being at the receiving end of a rant from the general direction of Clarence House if it doesn’t behave?

These professionals took on the most egregious examples of modalities lacking in any credible support: “medicines that contain no medicine.” They concentrated on alternative modalities and nutritional therapies that make unjustifiable claims about the ability of diets and vitamins to cure diseases, thinking these would be the most logical place to start. In his article, Dr. Colquhoun goes on to review some of the woo being funded by the government and their discovery of a surprising amount of politics behind things.

It is quite easy to get an impression that some of these fringe forms of medicine work better than they do. They form efficient lobby groups and they have friends in high places. They long for respectability and they’ve had a surprising amount of success in getting recognised by the NHS…

One can argue about whether it was money well-spent, but in the USA almost a billion dollars has been spent on research on alternative medicine by their National Center for Complementary and Alternative Medicine (NCCAM), which was set up as a result of political pressure from the (huge) alternative medicine industry. That has produced not a single effective alternative treatment, but at least it has shown clearly that most don’t work.

The placebo effect may seem harmless as long as people feel better, he said, but promoting modalities that appear to “work” by placebo comes at costs that aren’t often appreciated.

First it must be said that much of the apparent benefit of placebos like homeopathy isn’t a placebo effect, but merely spontaneous recovery. Echinacea cures your cold in only seven days when otherwise it would have taken a week. But when there is a genuine psychosomatic placebo effect, it can be a real benefit. As always, though, one must consider the cost as well as the benefit.

And there are a lot of hidden costs in this approach. One cost is the need to lie to patients to achieve a good placebo effect. That contradicts the trend towards more openness in medicine. And there is a major cost to the taxpayer in the training of people. If the NHS employs homeopaths or spiritual healers because they are nice people who can elicit a good placebo effect, the Human Resources department will insist that they are fully-qualified in myths. “Full National Federation of Spiritual Healer certificate or a full Reiki Master qualification, and two years post certificate experience” (I quote). That is one reason why you can find in UK universities, undergraduates being taught at taxpayers’ expense, that “amethysts emit high Yin energy”.

His article, which was published in The National Health Executive, a publication for Senior Health Service Managers, can be read in full here. He ends with what he was told by a government agency when he asked about the qualifications listed in its Skills for Health and learned there is even a division in charge of guidelines for talking to trees.

This issue of the urgent need for evidence-based medicine has taken on more seriousness in the UK than it has yet to here in the United States. For example, as we’ve looked at repeatedly, while the government spends countless millions of dollars on “healthy” diet and lifestyle programs to address child obesity — that lack evidence and have been shown to be ineffective and potentially harmful for young people — special care baby units now don’t have enough nurses to provide minimal care to sick and premature babies; the NHS is deciding how to ration care and which people are deserving of treatment; and hospitals have resorted to appealing to local residents for funds to buy needed diagnostic equipment for cancer, brain and kidney disorders.

Good doctors and nurses care about this stuff, and are willing to speak out even though it comes with considerable backlash, because they care about people. They touch people’s lives every day. And most of all, they understand that some day each one of our lives may depend on getting the best care. That’s why it’s important to keep hospitals and medical care top class.

Dr. Colquhoun shared an especially touching Christmas memory earlier this month that brought this message home. He described the snowy Christmas Eve when his son was born and rushed to the intensive care unit after his wife, seven months pregnant, developed a life-threatening brain hemorrhage. Thanks to the top-notch care of neurosurgeons, obstetricians and neonatologists, both his tiny son and his wife pulled through. Dr. Colquhoun posted a later photo of him holding his son for the first time. Little Andrew was so tiny he wore doll clothes knitted by volunteers.

No amount of homeopathy or therapeutic touch would have saved the life of his wife or son.

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December 28, 2008

Sunday morning papers — an exercise in critical reading

At first glance, readers may have thought that a government program had been shown to prevent childhood obesity. Today’s newspaper headline read: “Scheme to prevent child obesity hailed a success.”

According to the Northern Echo, the National Health Service for County Durham and Darlington Primary Care Trust are offering a 12-week program for children 8 to 11 years of age and their parents, called Junior One Life. It is said to be aimed at tackling “the growing problem of childhood obesity.” The scheme was reported to have been piloted last year and teaches “healthy eating” and fun activity.

The Darlington NHS webpage described the program’s goals for families “to change their attitude to food and activity.” The pilot scheme was conducted last September at Longfield Comprehensive Elementary and the NHS reported last year that if it was a success, they hoped to roll it out across the whole of Darlington.

It would appear to have been a success, right?

If so, it would be the first proven weight management program on earth to prevent child obesity with a healthy eating and activity scheme, let alone in just 12 weeks. That’s because, as the science has shown time and again, the natural diversity of sizes in children is not caused by food or activity. The UK’s own Health Survey for England data for the past decade has also shown no significant change in child obesity rates and children have grown taller as they’ve grown healthier. That begs the question of whether this program is really about child obesity or about telling families how the government thinks they should eat and live?

As it turns out, the Junior One Life program has not been shown to be a success at all. In fact, the NHS hasn’t even begun to evaluate it.

According to the NHS Darlington PCT Board Meeting minutes from last month, evidence-based interventions to address childhood obesity are still being developed. They are being finalized before being evaluated: “Evaluation of Junior One Life to inform development of group based intervention programmes in all areas to be in place in 2009/10.”

Evidence-based means having the evidence before a health intervention is implemented on children, not after the fact.

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Healing touch that doesn’t heal or touch

An article taking a critical look at the rise of alternative modalities in our healthcare system appeared in the Arts & Entertainment section of the Wall Street Journal. Perhaps its placement is why many healthcare professionals and health policy analysts may have missed it.

Mr. Steve Salerno, author of SHAM: How the Self-Help Movement Made America Helpless, began with an introduction to a foundation that offers alternative healing modalities:

Feeling a tad listless? Perhaps your DNA is insufficiently activated. You may want to consult the healers at Oughten House Foundation, specializing in "tools and techniques for self-empowerment through DNA Activations." Oughten House recommends regular therapy as part of its DNA Activation Healing Project, at $125 per hour-long session.

The foundation isn't as far from the mainstream as you might think. A survey of 32,000 Americans by the National Center for Health Statistics, released earlier this month, suggests that 38% of adults use some form of "complementary and alternative medicine," or CAM…

The Oughten House Foundation is headed by Dr. Robert V. Gerard, Ph.D. — whose doctorate is in metaphysical psychology — and Zeljka Roksandic — who is described as a “clairvoyant, psychotherapist, lecturer, artist, and healer.” It offers programs of their own creation, such as ZeRo Point healing, and Icon Code therapy, along with remote healing, angelic communications, advanced Reiki and life coaching. Icon Code Therapy, according to its website, reduces your “negative force fields” and “increases energy, rejuvenates cellular life, improves the immune system, quickly detoxified the body, and improves the circulation.”

Are these the sorts of CAM modalities that most Americans are really buying — as the NCCAM (National Center for Complementary and Alternative Medicine) survey seemed to suggest — or just what we’re being sold?

It’s the latter, trying to sell us on the popularity of CAM by hoping we’ll fall for the Ad Populum fallacy of logic. As it turns out, most Americans have not fallen for these types of CAM or those being taught at hundreds of nontraditional colleges across the country, such as as the Global College of Natural Medicine. There, Mr. Salerno wrote, “a 60% grade on an admission exam puts you on the path to becoming a nutritional consultant, master herbalist or holistic chef for animals.”

Based on the college’s curriculum and recent newsletters, students learn raw food preparation, how optimal health can be obtained by drinking more water, how lack of enzymes in processed foods cause degenerative diseases and chemical sensitivities, the prevention of seizures in epilepsy with “shoe smell therapy,” colon detox for kids, achieving positive vibrations with Bach flower essences, how to drain toxins from the body with cupping (placing a glass cup on the skin), acupuncture, homeopathy, healing with whole foods, dietary wellness with phytochemicals and antioxidants, and more.

In fact, if I wanted, I could beef up my resume, and add a few more letters after my name, with an inexpensive Masters of Science degree… in Holistic Health. Advanced degree students are also taught how to protect themselves with disclaimers.

The most offbeat and potentially harmful modalities, however, aren’t coming out of alternative institutions. They’re being taught at some 40 major academic medical schools across the country, funded by Bravewell Collaborative and NCCAM at the National Institute of Health, as covered here. It’s all part of today’s popular preventive health and wellness movement which, as Mr. Salerno reveals, is really one big, money-making con job:

This should be a laughing matter, but it isn't -- not with the Obama administration about to confront the snarling colossus of health-care reform. Today's ubiquitous celebration of "empowerment," combined with disenchantment over the cost, bureaucracy and possible side effects of conventional care, has spurred an exodus from medical orthodoxy. As a result, what was once a ragtag assortment of New Age nostrums has metastasized into a multibillion-dollar industry championed by dozens of lobbyists and their congressional sympathizers….

[A]t least 40 states have begun licensing CAM practitioners. Major hospital systems, notably Baltimore's Johns Hopkins and New York's Sloan-Kettering Cancer Center, incorporate CAM-based programs like aromatherapy and therapeutic touch, often bracketed as "integrative medicine." Indeed, one of the great ironies of modern health care is that many of the august medical centers that once went to great lengths to vilify nontraditional methods as quackery now have brought those regimens in-house. "We're all channeling East Indian healers along with doing gall-bladder removal," says Arthur Caplan, director of the University of Pennsylvania's Center for Bioethics. Mr. Caplan harbors no illusions about what's behind the trend: "It's not as noble as, 'I want to be respectful to Chinese healing arts.' It's more, 'People are spending a fortune on this stuff! We could do this plus our regular stuff and bill 'em for all of it!'"

Fees for CAM services are increasingly passed on to insurance through a creative — some might say fraudulent — interpretation of the Current Procedural Terminology codes that govern reimbursement for authorized services. Such creativity may soon be unnecessary if the alternative medicine proponents have their way. For example, ABC Coding Solutions, a medical-software company, has been promulgating a set of 4,000 treatment codes that cover "nearly every healing modality practiced by alternative healthcare providers," to quote one report. If such codes are fully absorbed by the health-care industry, CAM will have been mainstreamed — while bypassing all the customary peer review, controlled studies and other hallmarks of sound medicine.

How many consumers realize that these centers are laughing all the way to the bank? Thanks to well-funded lobbying efforts, CAM has received funding and political support from both State and Federal government agencies. As the website of that Global College of Natural Medicine, based in Santa Cruz, California, happily reported: “On September 24th, 2002, California Governor Gray Davis signed into law the most important Health Freedom bill in world history - California SB 577. The bill makes health care ‘wide open.’ Doctors of Holistic Health, Holistic Health Practitioners, Homeopaths, Naturopaths, Herbalists, Nutritionists, etc., are now free to offer services without harassment.” It says that California leads the nation in the percentage of healthcare dollars spent on alternative medicine and that it’s expected to increase.

CAM has been able to secure a place at the National Institutes of Health at NCCAM, but, Mr. Salerno writes, despite spending $1 billion in the past fifteen years, “the center has failed to affirm a single therapy that can withstand the rigors of science.”

Even the center's own fact sheets unfold as unintentionally comical. After noting that echinacea is "traditionally used to treat or prevent colds, the flu and other infections," the center concedes that "most studies to date indicate that echinacea does not appear to prevent colds or other infections." St. John's Wort as a natural antidepressant? "Two large studies, one sponsored by NCCAM, showed that the herb was no more effective than placebo in treating major depression." Evening primrose for hot flashes? "Does not appear to affect menopausal symptoms." And so forth. "It is the only entity in the NIH devoted to an ideological approach to health," writes Dr. Sampson, who has called for the center to be defunded.

As Mr. Salerno said, “it’s not like we’ve got billions to waste.”

In contrast to the placement of this article, the Wall Street Journal published an article in the Health section today promoting employee wellness programs offered by integrated health services of major insurance companies. The preventive health and wellness programs include “healthy” eating and weight loss plans, like Jenny Craig and Weight Watchers, yoga, and even spa visits. The article claimed that these wellness programs make workers more productive and save employers money in health care costs. Diets, yoga and other wellness modalities are among those listed at the NCCAM as unproven CAM. If the WSJ article had, instead, critically examined these modalities, perhaps it would have been placed in the Travel section.

Thank you, Mark!

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December 27, 2008

Father of Modern Medicine

Today is the 186th birthday of the father of modern medicine. Louis Pasteur (1822-1895) is widely considered one of the greatest benefactors of humanity. His diligent research led to some of the greatest discoveries in the causes and prevention of contagious diseases that have saved millions of lives. His life’s work gave birth to many branches of biological science — microbiology, bacteriology, immunology, stereochemistry, virology and molecular biology.

He was single-handedly responsible for some of the most important scientific concepts and practical applications of science. The single, most important contribution to medical science and modern medical practice was the germ theory. It led to the first vaccine for rabies and development of immunizations, aseptic surgical procedures, safe fermentation and food handling, and pasteurization.

To establish the modern scientific principles of biology and biochemistry, however, he first had to take on the entire scientific community and debunk the consensus that had been widely believed for centuries: spontaneous generation (abiogenesis). Back then, it was believed that life arose spontaneously from nonliving matter, such as maggots from rotting meat, akin to diseases from bad energy or thoughts. The origins of the belief in spontaneous generation went back to the earliest philosophers, such as the Milesian philosopher Anaximander from the sixth and fifth century B.C., the Greek philosopher Aristotle from the fourth century B.C., and the German naturalist of the thirteenth century Middle Ages, Albertus Magnus.

Earlier work of Anton van Leeuwenhoek, who invented the first microscopes and saw microscopic organisms, and Francisco Redi who showed that flies laid tiny eggs on decaying meat which gave birth to maggots, first questioned spontaneous generation. But these early skeptics were lambasted, using studies that are now understood as flawed. [There were hundreds of impressive-looking, published studies, and textbooks with long bibliographies, that seemed to support spontaneous generation.] Proponents continued to derive increasingly more complicated explanations to explain each study that failed to support spontaneous generation, arguing, for instance, that heat destroyed a vital life force or that spontaneous generation needed air.

During his lifetime, Dr. Pasteur was the object of intense opposition by virtually the entire scientific community. It was only his persistence and sound experimental and analytical procedures that finally compelled most biological and medical scientists to give up their ideas of the naturalistic origin of life and their treatment of disease based on this notion.

This is a story that is important for today because of the larger lesson he taught mankind: the scientific process. He showed how easy it is, even for scientists, to be misled to believe things that aren’t true without meticulous observations and understanding what makes a sound test of an hypothesis. He illustrated the importance of designing experiments to eliminate confounding factors and bias.

As Seung Yon Rhee, Ph.D., of the department of plant biology at Carnegie Institution of Washington and the principal investigator at the Arabidopsis Information Resource, wrote for the National Health Museum:

Pasteur's achievements seem wildly diverse at first glance, but a more in-depth look at the evolution of his career indicates that there is a logical order to his discoveries. He is revered for possessing the most important qualities of a scientist: the ability to survey all the known data and link the data for all possible hypotheses, the patience and drive to conduct experiments under strictly controlled conditions, and the brilliance to uncover the road to the solution from the results.

On the discipline of rigid and strict experimental tests he commented, “Imagination should give wings to our thoughts but we always need decisive experimental proof, and when the moment comes to draw conclusions and to interpret the gathered observations, imagination must be checked and documented by the factual results of the experiment.”

As she explained, the pattern of logic and brilliance of his experimental method are now well appreciated in modern scientific research, with its series of careful observations, and well-designed experimentations to test each hypothesis in increasingly more detail.

Later in his career, he was approached with a contamination problem in alcoholic fermentation, which was thought to be an entirely chemical process at the time. After careful examination, he found that the fermenting solution contained optically active compounds and concluded that fermentation was a biological process carried out by microorganisms. This hypothesis, called the germ theory, was followed by many elegant experiments that showed unequivocally the existence of microorganisms and their effect on fermentation…

The spontaneous generation theory was considered finally laid to rest in 1859 when the French Academy of Sciences held a contest for the best experiment to prove or disprove the theory. It was Pasteur’s famous experiments that refuted spontaneous generation and convincingly showed that microorganisms are everywhere, even in the air, and can contaminate solutions, but that air itself doesn’t create microbes.

Pasteur first filled flasks with beef broth and boiled the broth, leaving some flasks opened to the air to cool and sealing others. While the sealed flasks remained free of microorganisms, the open flasks were contaminated within a few days. Next, he placed boiled broth in flasks that had open-ended, long necks that he had bent into sharp S-shaped curves. Air could enter the flask, but airborne microorganisms could not — they settled by gravity in the sharp dip in the neck. As he predicted, broth in these uncapped flasks remained uncontaminated even months later. Then, when he tilted the flask so that the sterile broth reached the part of the neck where the airborne microbes had settled, the broth quickly became clouded with teaming life.

It was Pasteur’s simple, but elegant experiments, that struck the “mortal blow” to spontaneous generation. In doing so, he also helped support the understanding of contagious diseases and infections as caused by germs. As Dr. Rhee said:

Pasteur's intuited that if germs were the cause of fermentation, they could just as well be the cause of contagious diseases. This proved to be true for many diseases such as potato blight, silkworm diseases, and anthrax. After studying the characteristics of germs and viruses that caused diseases, he and others found that laboratory manipulations of the infectious agents can be used to immunize people and animals.

Scientific progress was made possible by the scientific process, which is simply a method of critical reasoning. The scientific community came to recognize the merits of the scientific method and it has resulted in the exponential advancement in science and technological discoveries we’ve enjoyed over the past century. As hypotheses fail to be supported in well-designed research, sound scientists move on. Junk scientists don’t, which is why unsound science also never progresses but continues to test the same things, hoping for different results. Incredibly, there are people to this day who reject the germ theory and the scientific process. Sadly, they are unable to recognize sound science from fraud, pseudoscience, ideology and the popularity of beliefs. This leaves people prey to all sorts of unsound things that can needlessly worry or take advantage of them - and it's very hard to help people when science and scientific evidence is rejected.

But even mainstream scientists and doctors can be taken in by flawed observations and statistics, failing to ask the right question, poorly-designed studies that are not fair tests of an hypothesis, and biased interpretations of the evidence. Cognitive disconnect requires constant diligence on everyone's part and to remember to keep our critical thinking caps on.

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What’s wrong with this picture?

National Health Services administrators have decided to order a massive 40 percent increase in bariatric surgeries for fat people in Yorkshire, the Yorkshire Post reported today. Government efforts to prevent obesity have had little impact, said the paper, leading to increasing calls for bariatric surgery.

While it is widely reported that some 71 percent of men in Yorkshire were overweight or obese in 2007 and 62 percent of women, wrote health correspondent Mike Waites, in actuality, the “levels of morbid obesity are below the national average with only one percent of men assessed as 'grossly overweight' and less than one percent of women.”

As he reported, the number of bariatric surgeries in England has risen ten-fold since 2001, when only 300 operations were performed. He went on to report, however, that the government health services has never evaluated the effectiveness of the surgery, including how much weight patients usually lose. The NHS hopes to set up standards that will enable such evaluations “to be carried out for the first time.” What other elective surgery receives government funding, let alone is mandated, with no evidence that it is safe and effective, and improves health?

How many consumers in the UK know that the Royal College of Surgeons in England, in partnership with the Surgical Specialist Associations, has embarked on what it calls a “National Surgical Fellowship Scheme?” In Hull and East Yorkshire NHS Trust and other NHS Trusts, the NHS has funded specialist training fellowships in upper gastrointestinal and laparoscopic surgery for consultants to now learn bariatric surgery (lap Bypass, lap sleeve gastrectomy and bands). Commencement was this past August.

Mr. Waites completed the disconnect by noting that government efforts to prevent obesity, by addressing popularly-believed diet and exercise causes, have proven to have little impact. So, a massive government programme is being launched in 2009 to target diet and exercise.

Government health officials don’t seem to quite get the evidence-based medicine theory.

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December 26, 2008

Suffer the little children

Medical and human rights organizations talk about the need to safeguard children and help ensure all children are vaccinated against the most crippling of preventable childhood diseases, but we rarely hear about efforts to dispel anti-vaccination myths by groups beyond our borders. Most of us would probably find it inconceivable that anti-vaccination junkscience, especially targeting innocent children, would be used for political purposes to spread hate.

Well-to-do parents in upscale regions of the United State may have more of a luxury to follow specious anti-vaccination myths because the costs aren’t nearly as deadly as they are for parents in some regions of the world. Millions of parents struggle every day against disease, poverty and lack of basic educational opportunities for their children. These same areas have rising rates and re-emergences of childhood diseases that have been mostly eradicated here. Like polio. Yet, these are the very same areas where anti-vaccine propaganda has been the most intense.

This tragic and ongoing story has been virtually ignored in mainstream media here. It’s as if facts are un-politically correct, somehow. But each development over recent years has become more horrifying than the last.

Today, the Times in the UK reported that the Islamic fundamentalist Taliban, which has control over a large part of the Swat district in Pakistan (North West Frontier Province along the border with Afghanistan), has ordered the closure of all girls’ schools, and threatened parents and teachers of dire consequences if their ban is not complied with. It is not an idle threat. Militant Taliban have destroyed more than 125 schools for girls in the region this year and more than half of all girls have stopped attending school because of the threats. According to the Pakistan Coalitions for Education, these represent nearly a quarter of the 490 schools that teach girls in Swat.

As the Daily Times reported today, the Taliban has issued a January 15th deadline otherwise they will bomb all schools that allow girls to get an education. “We cannot say anything because the people and the whole government is helpless before the armed people,” said one social worker in Swat. This is the future of these girls.

Attacks on education for girls isn’t confined to the Swat district. As the Times reports, over the past two years a hundred schools have been burned down in other tribal areas, leaving countless children with no access to education.

According to Afghanistan’s Ministry of Foreign Affairs, UN ambassador Dr. Tanin spoke at a UN Security Council meeting on December 19th, describing how the lives of children, especially girls, have been devastated by terrorists. “Terrorists are recruiting, training, and exploiting children as combatants and suicide bombers,” he said. They not only attack civilians who oppose them, but “they attack international workers and create an environment where humanitarian aid cannot reach those who most desperately need it. Vulnerable girl students are a main target of intimidation. A few days after this report was completed, a brutal acid attack on fifteen young girls on their way to school blinded some and permanently scarred others.” He urged the UN Council to not downplay the seriousness of the threat. “It is the Taliban and other terrorists groups that remain the main violator of human rights, including children's rights, in Afghanistan,” he said. He urged the UN to not only condemn the use and recruitment of children for terrorists activities, but these continued attacks on schools and healthcare providers, and “in particular, the use of barbaric tactics to repress and intimidate girls.”

Terrorist efforts have crippled children’s futures in another way. Muslim clerics have prohibited polio immunizations for children and used propaganda and violence in their anti-vaccination efforts.

Government health officials, the UN and other relief agencies have been working for years to get polio and other immunizations to children. When health officials seem to have made peace agreements with Taliban leaders to allow vaccines to reach children in regions they control, it’s repeatedly been followed by polio vaccination programs coming to a grinding halt. Dr. Waheed Khan, health director for the city of Peshawar, and a former official with the state’s Expanded Programme of Immunisation (EPI), has reported for years that vaccination efforts have been thwarted in Taliban strongholds, even as cases of crippling polio among children rise.

Polio is re-emerging across Pakistan, which has one of the highest rates of polio in the world. It is one of only four countries on earth where polio is endemic. The others are Afghanistan, India and Nigeria. “The situation is worrisome, very, very worrisome,” said Dr. Khan. “The biggest danger is that even previously polio-free cities are becoming infective, leading to an uncontrollable situation.”

The World Health Organization’s Global Polio Eradication Initiative has similar concerns, according to spokesperson, Oliver Rosenbauero. The “recent spread of polio into previously polio-free Islamabad and Punjab is alarming,” he said. WHO recorded 32 cases of polio in Pakistan in 2006, up from 28 in 2005. Between January and September 5th of this year, 43 cases had already been recorded. As of November, the WHO says 103 cases have been reported in Pakistan and 31 cases in Afghanistan. The most serious situations are in tribal areas of the NWFP, along the border with Afghanistan, under Islamic fundamentalist Taliban rule.

Although some religious leaders support the government vaccination campaign, EPI health workers admit that in tribal areas such as Swat, Bajaur and Kurram, the militant Muslim clerics have strangled efforts. In 2006, two vaccination workers were shot and killed on their way back from negotiations with a local council trying to gain cooperation for childhood vaccinations. In June of this year, four volunteers were kidnapped, said Dr. Kahn. “In areas under the militant Taliban, our volunteers sometimes encounter severe beatings,” he said.

Efforts to elicit the cooperation of tribal communities have had mixed results, with EPI officials saying some tribal leaders have denied vaccination workers to immunize children in regions they control until the government agrees to road or sewer projects, or continued violence against workers even during peace agreements. Shortly after accords were again reached between the government and militants in July, militants began a new and even more aggressive campaign directed against polio vaccination workers, IRIN reported.

On September 21, 2007, Radio Free Europe, followed by Islam online, reported that as part of a UNICEF program after a recent outbreak of polio, a deal had finally been reached with Taliban leaders to allow child immunizations. “I hope these vaccination campaigns will continue to be used as a bridge towards peace,” said Arshad Quddus, a medical officer with the World Health Organization.

But on September 16, 2008, the WHO reported it was forced to cancel an immunization drive after Taliban Muslim jihadists killed two doctors who were providing immunizations to children. The program had been due to finally start on September 21, 2008 and was intended to reach 1.2 million Afghan children under age five.

The WHO and other humanitarian groups, driven by courageous workers, have been able to reach many children. The Rotary Club of Pschawar in Pakistan reported that it was able to reach children in a 3-day door-to-door immunization campaign to 320 homes a remote and dangerous area on the Pakistan-Afghan border in September of this year. But the most dangerous regions are still inaccessible.

Violence against those who oppose the Taliban has caused public health vaccination teams to stay out of these areas. Melisa Corkum, a UNICEF communications officer, told Reuters: “Parts of Swat and parts of FATA, we haven’t been able to go and immunize children for quite some time. So that means we have a build-up of susceptible children that haven’t been immunized.” Anyone who has tried to vaccinate in these regions run by Muslim clerics is “really putting themselves at risk in these areas,” she said. In the Swat area alone, UNICEF estimates about 160,000 children have not been able to be vaccinated, according to Muqeem Khilji, spokesperson for the EPI.

The difficulties in bringing polio immunizations to children to these war-torn areas brings a better understanding of why parents also feel little option but to comply with militants' threats. “When order, security and economy collapse, people do what they need to survive,” said retired air force Brigadier-General Don Macnamara, “and threats are an imminent part of life.” Progress in the government’s and UN efforts to vaccinate children and bring humanitarian aid and health care to regions of Afghanistan have largely been successful with the support of NATO International Security Assistance Forces, and efforts to rebuild the Afghan National Policy and National Army to strengthen the country’s security, according to Macnamara. “A total of 7 million children have now received vaccinations through our polio eradication program,” he said, although new cases in the southern region demonstrate the need for continued vaccination efforts.

Beyond threats of violence, Dr. Khan said the main hindrance in efforts to immunize children against polio have been extremist religious leaders spreading propaganda, conspiracy theories and superstitions. Beliefs in superstitions, such as the ability of polio vaccines to sterilize children or cause diseases like HIV, are behind most parents who actually refuse to vaccinate children, he said.

Radical Islamic groups have not only ordered parents to not vaccinate their children, they have led anti-vaccination propaganda. Radical Islamic clerics, such as Maulana Fazlullah, have convinced residents that U.S.-manufactured polio drops are designed to sterilize Pakistanis and reduce the Muslim population, he said. Some parents have been convinced that to vaccinate their children is tampering with the will of Allah, said another EPI official.

A spokesperson for Tehrik-e-Taliban, Fazlullah's militant organization, reported that Fazlullah’s sermons have stressed that those who are crippled or die from polio are martyrs. He claims that the polio vaccines are made from pig fat and are haram, or forbidden for Muslims.

Maulana Fazlullah, son-in-law of the leader of the banned organization, runs a radio station in the Swat region actively warning people to “beware” of polio vaccination workers and telling parents to not vaccinate their children. The 28-year old Maulana calls the polio vaccination a “conspiracy of Jews and Christians to make Muslims impotent and stunt the growth of Muslims.” If it is still difficult to conceive that any ideology or hatred against Christians, Americans and Jews could be so extreme as to intentionally be used to harm innocent children, the recent massacres of Jewish people in Pakistan have accentuated that reality.

Maulan Radio is not only against polio vaccination but also against the formal education of girls, women working outside the home, allopathic medicine, and science and technology, reported Sadia Qasim Shah.

Dr. Khan believes that Pakistan will only be made polio-free when educational efforts can defeat superstitions and misperceptions. “To bring about an end to polio in this country, we need to change the attitudes of people first and foremost,” he said. “We will win this battle only when parents all over the country believe that inoculating their children is a necessity.”

As with most health scares, anti-vaccinations myths are based on ideologies, rather than good science. And the innocent are most harmed.

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