Ben Goldacre is a physicist and science writer. Along with Richard Dawkins and Simon Singh, he is a high profile advocate of rigorous scientific method, and is furiously exasperated at the dumbing down of science. This book is his attempt to educate the reader to look critically at science.
He begins by conducting some experiments on a couple of recently fashionable treatments; Aqua Detox footspas and Hopi ear candles. Chemical analysis of the brown water left following use of the footspa (supposedly full of released toxins) reveals only rust from the oxidation of the iron electrodes. The smell of chlorine (also supposedly toxin release) is actually chlorine released from the salt in the water as part of the oxidation process. He effectively demolishes any credibility for the validity of this therapy; in the process demonstrating how ‘expensive, tedious and time-consuming’ it is to conduct the test; hence, presumably, the reason for the proliferation of unchallenged and pseudoscientific treatments. Next, Hopi Ear Candling: in patients given this treatment regularly for a year there is no reduction in earwax. As a more informal experiment, he tastes the residue in a candle following the procedure on himself to find it tastes of candlewax and not earwax.
He then moves on to the whole notion of detox. While he feels that an unhealthy diet has negative effects on the body in myriad ways, and that once in a while it might be good to purify the diet, drink less alcohol and eat more salads, he says that the idea that poor food leaves a residue which can be later extruded, is a marketing invention. He believes there is a cultural need for a process of purification and redemption which used to be justified by religion, but which is now seemingly underpinned by science, wrong though that science might be. Similarly he finds that essentially commonsense advice – that regular study breaks, intermittent exercise and drinking when you are thirsty enhance your ability to concentrate – is being marketed as Brain Gym in schools. Taxpayers are footing the bill for introducing this around the country, with its “nonsensical” claims including the one that ‘holding water in your mouth’ enhances its absorption.
Swiftly dismissing the idea that expensive moisturisers can actually be any more effective than a £10 half-litre tub of hydro base (or even his own recipe – equal parts of olive oil, coconut oil, honey and rosewater) Goldacre moves on to homeopathy. It is no surprise that he simply cannot believe that ‘little sugar pills which seem to work’ can possibly have a therapeutic effect, and he finds scant evidence to change his mind. He uses homeopathy as an example in how to read a randomized controlled trial. This is a useful chapter explaining randomisation, blinding and meta-analysis. He believes that the complementary and alternative medicine industry lacks this knowledge and expertise, that their “literature and debates drip with ignorance“, and its proponents are “vitriolically angry” at anyone who dares appraise their flawed trials. He concludes with a very sensible suggestion that a simple, evidence-based medicine hotline be set up so that anyone wishing to run a trial in their clinic could be advised how to do it properly.
Fittingly, he follows this chapter with a discussion of the power of the placebo effect. Amongst other examples: four sugar pills work better than two in healing gastric ulcer; pink sugar pills have a more stimulating effect than blue; oxazepam is more effective at treating anxiety if given in a green form, but more effective for depression if in a yellow tablet; sedatives are more effective in capsule form than pill form; brand name painkillers are more effective than exactly the same tablet in non-branded packaging; pain relief works better when subjects are told it cost $2.50 as compared to 10c; placebos for Parkinsons actually show increased dopamine release in the brain; sugar pills handed out with an outrageous oversell worked better than those the doctor professed to be uncertain about, and giving a patient a diagnosis improved outcomes. Goldacre ascribes the success and popularity of alternative therapies to the placebo effect, part of which is due to the therapeutic relationship. Orthodox medicine, he says, is handicapped in this by brief consultation times and formalization of consent. Whilst agreeing that patients deserve the truth, he quotes Raymond Tallis, a doctor and philosopher
“The drive to keep patients fully informed has led to exponential increases in the formal requirements for consent that only serve to confuse and frighten patients while delaying their access to needed medical attention.”
He believes that the authoritative, paternalistic, reassuring approach and the ‘blinding with science’ of the Victorian doctor has found its place in alternative medicine. It is the relationship and the ceremony of their interventions, rather than their treatments, that are having the positive effect on healing.
The nutrition industry, and particularly Gillian McKeith, then earn Goldacre’s contempt, with their flawed interpretations of research and fanciful diagnostic methods: for example, the tongue is “a window to the organs – the right side shows what the gall bladder is up to, and the left side the liver”. He looks up McKeith’s references to find they come from books such as “Spiritual Nutrition and the Rainbow Diet” (a book I was quite taken with some years ago, and which I kept on my bookshelf purely for the amuseument it afforded to various friends. I eventually replaced it with “Enlightenment through Orbs”). He is sceptical even that McKeith’s TV presence has encouraged healthier diets over the long term. He then rattles through illuminating exposes of dodgy fish oil experiments, Patrick Holford of the Optimum Nutrition Bible, and alternative AIDS treatments, before setting his sights on mainstream medicine.
He agrees that medicine can and does do terrible things, and that only 50-80% of medical “activity” is evidence-based (the figure is much lower for treatments), but his real wrath is directed at the pharmaceutical industry or “big pharma”, as he calls it. He explains how a drug is brought to market (at the cost of about $500million) and how the development of new drugs is driven by the drug industry, who have a vested interested in the success of their trials. He enumerates the various ways in which their trials are manipulated: by studying the efficacy only amongst young people who are likely to respond better; by comparing against a placebo rather than the best available treatment; by use of an inadequate or too-strong dose of the competing drug; by not asking about side-effects (apparently loss of orgasm occurs in between 2% and 73% of patients taking SSRI drugs, yet this has not been listed despite 23 other side effects being deemed important); and by using surrogate outcomes (eg report reduced cholesterol despite no success in reducing cardiac deaths). If the results are negative: mention them only briefly in the text but not the conclusions; don’t publish them at all, or only after a long delay (as happened with data suggesting SSRIs might be dangerous), or start to manipulate the statistics. Again ways of doing this are clearly listed: assume any correlation proves causation; if the treatment group is already doing better than the placebo group at the start, don’t adjust for it; ignore those who have dropped out of the trial (who are more likely to have had poor results or side effects); clean up the data, by deleting anomalous findings or drawing attention to them, according to which helps your case; carry the trial on only for the period of time it takes to show a positive result; ‘torture the data’ to find at least one subgroup which responded well; and finally, just run the figures through every statistical test available until you find one which gives some sort of positive result. It seems remarkably difficult to detect the ways in which drug companies skew findings and hide side effects and the tens of thousands of deaths from Vioxx show the potentially tragic consequences. Goldacre believes that publishing your protocol, specifically the methods of your trial, before you start, would eradicate most of the problems in one fell swoop.
Lightening up a bit, we are then taken on a romp through various media science stories (“By the year 3000, ..willies will get bigger – and women’s boobs will become more pert”) and shown how insubstantial they are. These stories are apparently funded by PR companies (the one above turned out to be promoting a blokey TV channel). He thinks that the background to the media’s trivialization of science is that the golden age of discovery of miracle cures is over. Between 1935, when doctors were “useless”, and 1975, transplants, dialysis, CPR, CT scanners, heart surgery and “almost every drug you’ve ever heard of” appeared on the scene. But today the pace of research has slowed dramatically, which is a major problem for media outlets wanting exciting headlines about health. He is frustrated that newspapers routinely dumb down science stories reinforcing the “parody” of science that “science is about groundless, changeable, didactic truth statements from arbitrary unelected authority figures”.
Above all else, Goldacre simply loves science and can‘t bear to see it misrepresented and abused. He quotes Zen and the Art of Motorcycle Maintenance
The real purpose of the scientific method is to make sure nature hasn’t misled you into thinking you know something you actually don’t.
He explains the pitfalls of relying on intuition without using science to challenge it (for example, the large number of cot deaths which occurred following Dr Benjamin Spock‘s well meaning but unresearched advice to lie babies to sleep on their fronts). But then counters it with a frightening chapter showing the “Meadowesque” problems with blind belief in statistical evidence.
The book concludes with the stories behind the MRSA scare and MMR “hoax” and a plea to reverse the process of dumbing down. We are implored to complain about poor journalism, write our own blogs and in general demand higher standards. This is a really great book: compulsive, intelligent, powerful and packed with illuminating and fascinating facts, insights and anecdotes. But before you hang up your clinic coat, and vow never to do a CV4 again, I would suggest you get hold of the perfect antidote: Tim Parks wonderful account of his journey to health in “Teach Us to Sit Still: A sceptics guide to health and healing”.