What it means to be a doctor

Two nice quotes from one of my favorite podcasts: Quakcast

1. "Becoming a doctor mean learning to be comfortable with incomplete and changing information."

2. "Becoming a specialist is being ignorant... with style."

These quotes I think are funny and since I am also teaching at a medical school I can say that in my experience these quotes are also relatively accurate. I always get surprised at the many changes that can occur from one edition of a textbook to the next, although I must hasten to point out that there is a large proportion that does not change to. It gets even worse if you compare different textbooks or say journal papers.

Does this mean that doctors are merely shooting at random? No, they are (if they are good doctors) basing their decisions, diagnoses and treatments on the best available evidence - and that is the doctors which have the greatest success in terms of healthy patients (read Neurologica blog for more on this).

So if you are a doctor or becoming a doctor accept that there is rarely such a thing as perfect knowledge, and if you are a patient accept that doctors cannot always say things with perfect certainty...

Popular fallacies of alternative and complementary medicine

In the most recent issue of the magazine "Skeptic", Harriet Hall, also known as "SkepDoc" writes about three fallacies that you will encounter very frequently if you engage in discussion about alternative or complementary medicine. I will of course not plagiarize Hall's article, but what I am writing here is her article, filtered through my brain (I have written about related matters here and here)...

The fallacies that you will inevitably hear are the following three;
(1) It is "natural" (and hence better for you)
(2) It has been used for a long time (and if it didn't work people would have stopped using it)
(3) It works for me (or a friend or a spouse or a friend of a friend...)

So natural is good by default ehh? In this form the statement sound very categorical, and hence, put in this fomr, the claim can be falsified by a single unambiguous counter-example, and there are plenty... Curare, a compound extracted from nature (and thus a natural compound?) will paralyze you and hence is not recommended unless you need to be still during a surgery. There are many different, naturally growing mushrooms, which will kill people who try to eat it. There is also the fen-phen scandal where a product which was advertised as an alternative medicine was later shown to have severe side effects, despite the fact that the active ingredient was "natural".

Ok, sure, there are a few extreme counter-examples, but still, isn't natural products better in general? Well this is certainly debatable and I would not jump to verdict just yet, however, the evidence to date actually tells the opposite story, namely that natural is often worse than "synthetic" (or whatever you won't to call it). Plants which are sprayed with pesticides are protected from potential predators and therefore they can use all their energy to grow. Now that I think of it, it is rather similar to us humans, in peacetime we can spend our energy on building schools and being nice to children and that sort of stuff... Plants which are not sprayed are not given their protection and therefore they have to use allot of energy on chemical warfare (or the plant-equivalent thereof). Basically they produce chemicals which will make the predator (us), sick.

But don't synthetic pesticides make you sick too? In large quantities they might (just like natural pesticides). However, pesticide control is rather strict and the chemicals used are tested so that they are of minimal danger to us... I have written more about this issue here.

The second argument says that if something has been used for a long time then it is because it is good. Again there are many counterexamples. Some people persist in using astrology even though it has been falsified over and over again. Astrologers cannot do what they claim to be able to do, and add to that the fact that their quackery is based on an astronomical model that is very out-dated. Still people are still using it… If we would have strictly gone by the "old is good" rule we would still be drilling holes in people's head to relieve headaches (here you can buy your own drill kitJ), and what about all new techniques and medicines that are developed? Are we to discard them because they are new? The fact of the matter is that we cannot rely on tradition. The way to test whether a therapy is good or bad is to do a proper, scientific test where it is possible to isolate the effect of the medicine from other factors such as placebo.

The last argument (it works for me), is the one that I have most sympathy for. In my opinion we should have respect for individual differences as well as the power of people's belief to cure them or at the very least make them feel better. If someone starts taking extra vitamins to bolster their immune system and then they do not get sick for a long time then everything is great (as long as they don't overdose which could be dangerous). Similarly, when I tell people that I am studying the brain I am often told about some therapy or mental training that I have never heard about before but which has changed their life. In those cases I normally just say that I am happy for them. However, the mistake that is often made is to assume that just because you have experienced miracles everyone else will too. Even with most conventional medicines which have a proven effect that is greater than placebo, it doesn't work for everyone. The point is that what works for you might not work for other people. Most alternative therapies have not been tested (or they have been tested with no effect). The responsible policy if you ask me is that doctors advocate therapies which have a proven effect, but do not prevent people from spending their money on other therapies (as long as they are not harmful)…

Dangers of radiation in the home

The best Swedish site for news on technology, in my opinion, is www.idg.se. Today they have an article on radiation in the home. The article is based on an interview with Maria Feychting professor in epidemiology at Karolinska Institutet. The article discusses the danger of the radiation associated with products that are becomming increasingly common in ordinary homes. I am speaking of mobile phones, routers, wireless keyboards and mice, bluetooth headsets and dect phones.

The conclusion of the article, briefly put, is that there are no scientific evidence that this radiation causes any harm. It is a fact that studies showing potential dangers of radiation get much more attention than studies which show zero effects, even though the latter type are much more common. Furthermore, most of the studies which have shown slight biological effects of radiation have subsequently been replicated with contrasting results i.e. the latter studies did not find any effects.

I think that one of the reasons why some people are so afraid of these things is the fact that they radiate, and we all know that radiation is bad right? No, not necessarily so. Radiation can be your friend to. If it were not for the radiation from the sun we would not be alive. Similarly, seeing involves the capture of radiation by photoreceptors in the back of your retina. In fact we are all rich sources of radiation which you can see for yourself if you have a camera that pick up infrared wavelength.


But isn't that different? Sure some sorts of radiation are more dangerous than others. Cosmic rays which arive from outer space are extremely rich in energy, and alot of that type of radiation would be bad for you. Similarly, X-rays will slightly increase the risk of cancers because it is rich in energy. But what about the radiation from all those home devices? This radiation is lower in energy than normal visual light, so you are very unlikely to get cancer from this type of radiation. These devices actually emit microwaves, just like your microwave oven. The difference is that the radiation is not contained within a box, and also the power is 10,000 smaller than in an ordinary microwave oven (for a dect phone it is 100,000 times smaller). If you want a different point of view on these issues, you can visit this page.

The article also gives some quick answers to the following questions:

1. Does radiation from mobile phones cause cancer: False

2. Will using a bluetooth headset reduce the amount of radiation you are exposed to: True (because a bluetooth headset has a much lower effect than the mobile phone)

3. A dect phone emits more radiation than a mobile phone: False

4. A 3G phone radiates more than a GSM mobile phone: False

5. More wireless devices in the home will make it more dangerous: False

6. A new router radiates more than an old router: False

7. It is dangerous to have your mobile lying next to you when you are sleeping: False

8. The mobile will emit less radiation if you hold your hand over it: False (actually it will radiate more becuase that is necessary in order to communicate the station.

9. Even the good old cable hardware emits radiation: True (anything with a current in it, a cable for instance, will generate a magnetic field which is also basically a form of radiation.


I want to end with a personal reflection on an issue which I think is highly relevant yet often forgotten. Mobile phones, which as mentioned is the device which has the highest effect and thus the highest radiation, has been around for about two decades now. In spite of their popularity, there has not been any increase in cancers in this timeperiod. This "natural experiment" shows that if mobile phones have any effect at all on the human body, that effect have to be very subtle. Pretend for a moment that there has been a slight increase in some obscure form of cancer, or other type of disease, that is a result of mobile phone radiation. Even such a necessarily slight effect would pale in comparison to the enourmous benefits of being able to call ambulances, fire fighters and the police from almost anywhere on this planet. Hurray for mobile phones!

Medical myths

Rational as I may be I sometimes engage in superstitious behaviors because of advice I have heard a long time ago and then stuck. For example, when I have a flu I usually overdose on C-vitamin. I believe that this piece of advice was made famous by Nobel prize winning scientist Linus Pauling who asserted that C-vitamin could cure the common cold. According to other sources that I trust more on this particular issue, such as Harriet Hall, also know as the "Skep Doc", a C-vitamin overdose will at best shorten the common cold for a day, and that is for people who do not eat a lot of C-vitamin in the first place (I am one of them why I may perhaps benefit somewhat), at worst a C-vitamin overdose can make you quite sick.

Two other behaviors which I sometimes engage in is drinking coca cola when my stomach is upset, and eating garlic when I have the common cold. Quick google searches did neither prove or disprove the efficiency of these two questionable treatments. Perhaps someone out there know something about it (in which case I hope you will share your knowledge).

What I really wanted to write about in this post is an article published in the British Medical Journal in which widespread myths, often reinforced by doctors were punctured. Some of these myths I believed in firmly until I saw the article. For example I have thought for a long time that reading in dim light is bad for your eyes. Now, becuase of this article, I know that there is no good evidence to back this claim. I had been wrong, but now I have changed my provisional world model to fit the new data (I stand corrected to put that more simply).

However, I am proud to say that I never bought into the myth that you only use 10% of your brain. Then again, I am a brain researcher so perhaps I cannot brag to much about this accomplishment. The idea, though popular in books such as Uri Geller's "Little Mind Power Book", is completely absurd. Would evolution allow 90% of our brain just sit there and do nothing, I think not. By the way, the claim can be easily disproved by sending a person into an FMRI and watch how the entire brain lights up which is an indication of energy expenditure (maybe with the exception of people like Uri Geller). Furthermore, in contrast to predictions of the "we only use 10% of our brain" hypothesis, removal of almost any part of the brain will result in clear symptoms,


The entire list of medical myths which are debunked in this nice article are as follows. Take a look at the article if you are not willing to take my word for it (there are nice references as well).

1. People should drink at least 2,5 litres of water per day
2. We only use 10% of our brains
3. Hair and fingernails continue to grow after death
4. Shaving hair causes it to grow back faster and be coarser
5. Reading in dim light ruins your eyesight
6. Eating turkey makes people especially drowsy
7. Mobile phones cause electromagnetic interference in hospitals

Complementary and alternative medicine - Spontaneous recovery from disease

Alternative and complementary medicine refers to products and practices which are not part of the standard medical procedure that you get when you go to a hospital. Though the terms are often used interchangeably, alternative refers to when a practice aspires to replace standard medical care whereas complementary practices only aspire to complement standard medical procedure. For sure, for sure, medical research is far from a complete understanding of the physiology and anatomy of humans, and there are almost certainly many effective remedies which are not a part of the standard repertoire today. In the future we will no doubt see many advances in science and in consequence, new therapies to treat disease.

Having said this, complementary and alternative medicine suffers from what I consider to be a much more serious problem. First of, many of the techniques and practices used in alternative and complementary medicine have never been tested, or have not gained any support, in controlled studies and hence they have never proved to have any "real effect" (as opposed to placebo effect which they probably do have). Even more serious, because alternative therapies have often not been tested properly, it is hard to tell whether they have any serious side effects. What is almost certain is that if a particular substance has any effect at all, then it is more than likely to have side effects as well (see table at bottom of this article).

Sometimes alternative practices turn out to be effective and when they do they are eventually assimilated into standard medical practices. To be fair, this assimilation process can sometimes be agonizingly slow and some doctors are probably too conservative, however, the essence of the matter is that when an alternative treatment or therapy has gained enough support in studies it will cease to be "alternative" and become "standard". This is to some extent true for acupuncture, which is now used occasionally as a treatment for various conditions even though it has long been controversial. However, importantly, the mechanism that makes acupuncture work seems to be different from what has been claimed by those who have used this procedure in the past. No meridians have ever been demonstrated. Instead it seems that acupuncture stimulate pain sensing nerve endings. These nerve endings in turn exercise a form of lateral inhibition meaning that they block other pain sensing nerve endings around them, thus preventing the patient from experiencing pain in that area.

Complementary and alternative practices can often give the illusion of being effective because we recover spontaneously from diseases. We have an impressive immune system, which deals with seemingly limitless pathogens in an extremely efficient and competent manner. I am making up the numbers here, but say that after taking a certain herb 90% of all people recover from the flue within a week. Wow, surely there must be something to it then? But wait a minute. Almost everyone (say 90%) recovers from the flue within a week if they just stay home in bed. Suddenly these herbs do not seem that fantastic, and they seem even less attractive if you take into account the often excessive price tags.

Back pain is another example that deserves mention, and these figures I am not making up (they come from a lecture I attended recently). Nine out of ten (90% that is) cases of acute back pain will go away after one week. Combine this with the fact that 60-80% of all individuals will experience back pain sometime in their lifetime and what you get is an awful lot of cases of back pain that goes away in one week. Not surprisingly, at least not to a cynic like me, there are a huge number of alternative or complementary therapies for back pain, and they all seem really successful as long as you do not compare them to no treatment at all…

Here is my advice, my alternative therapy if you like. If you experience back pain, and don't have any other serious symptoms such as your vertebrae penetrating your back muscles (in which case I would advice going to a doctor), don't spend your money on all sorts of alternative/complementary therapies, rather relax for one week and see if the pain simple goes away (in most cases it will). Once you have recovered, use the money you would have spent on a therapy on something nice, such taking your girlfriend to a cozy restaurant. If the pain does not go away after one week, go see a doctor and have your back checked up…

Writing about alternative medicines is something that really warms my heart. I have written about homeopathy here, here and here, and here I have written about the role of the placebo effect.

Irrational fear 1: Pesticides

About three months ago I wrote a post on natural foods and the highly exaggerated danger associated with pesticides. I cited research done by Bruce Ames (see picture), Professor of biochemistry and molecular biology at UC Berkeley. In this very interesting interview, Bruce Ames gives his view on organic foods. In the following excerpt from this interview Ames explains that the reason why he is against spending more resources on natural foods is not that it contains more carcinogens but rather that the production and in consequence also the products is more expensive. More expensive fruits and vegetables means less consumption which will result in more cancers:

Ames: Yes. I'm much more interested in preventing cancer. Then we have to get out to the public what's important. If you tell them about trivia all the time, they get completely confused, and it's counterproductive. I just think all this business of organic food is nonsense basically. We should be eating more fruits and vegetables, so the main way to do that is to make them cheaper. Anything that makes fruits and vegetables more expensive may increase cancer.

When I cite this information people often ask where Bruce Ames gets his money from. Is he really trustworthy? This is a fair question when you take into account the fact that the food industry is a big industry, and if organic foods would suddenly become the public choice it would certainly be rather detrimental to many companies. What many people seem to forget though is that producers of organic foods also have money waiting for them, should they manage to sway the public opinion. Unless it is suggested that organic food producers have a superior morality, immune to economic incentives, this is not a valid argument, after all the economic incentive is there for both sides. Maybe those the people who tell us that organic is the way to go do so because they would get rich if people followed their advice?

I feel quite confident that Bruce Ames is not bought by the food industry. Why? Partially, I believe Ames is a good guy because of what my intuition tells me. When I read the interview (referenced above) with this scientist he just doesn't strike me as a man who has sold his soul to the devil, quite the contrary in fact. However, the main reason why I don't think Ames is bought by the food industry is that he is also the man who first proved that many synthetic pesticides are carcinogenic. For quite a while he was a hero to all the natural food proponents.

Bruce Ames showed that indeed many man made chemicals are carcinogenic, but what reason do we have to assume that natural pesticides aren't also carcinogenic? Ames did not make this assumption and when he tested natural pesticides, which are created by the plants themselves as a protection, he found that pretty much the same proportion of natural pesticides was carcinogenic. Furthermore, Ames discovered that plants which are not treated with synthetic pesticides (i.e. natural foods) contain more potent carcinogens than plants which have been treated with pesticides. (Things can be more or less carcinogenic; for example, even though mushrooms contain 50% carcinogens they are very weak and therefore doesn't do a lot of damage whereas coffee contains much stronger carcinogens.) Read my previous post if you want to understand why. Add to this that 99.9% of the pesticides that we ingest are natural pesticides and you will understand why this post is about irrational fear.

Here we are worrying about 0.1% of the pesticides we ingest which according to the data are, if anything, less mutagenic than the other 99.9%. That is what I would call irrational fear…

James Randi

This week I want to pay a tribute to a man that I admire very much, the skeptic James Randi (see picture) who will turn 81 in august. Randi, in a sense, is a man with two faces. First there is "The Amazing Randi", a world famous magician who has performed many seemingly impossible tricks. Among his achievements Randi is the holder of two world records. On one occasion Randi outperformed the infamous Harry Houdini when he spent 104 minutes in a sealed coffin on the bottom of a swimming pool. He earned his second entry into Guiness world records when he came out alive after having been frozen in a block of ice for 55 minutes. Does anyone know how this was done?

Magicians are of course interesting and fun, however, it is not magic skills that makes Randi unique. Like the just mentioned Houdini, James Randi is a skeptic. He has openly admitted that he has never performed any real magic in the supernatural sense. In other words, all the magical shows that we laymen find impossible or at least incomprehensible have merely been trickery. This of course begs the question of whether other people who seem to have similar magical talents are also just using tricks. My belief is that they are merely using tricks, and I have never encountered any evidence (excluding anecdotal stories) that has made me contemplate this. Interestingly Randi has once been accused of being a fraud in the opposite sense. Once when he performed a man claimed that Randi was in fact using psychic powers and that he is lying when he claims he is using trickery.

Nevertheless, our dear magician is perhaps most famous for his one million dollar paranormal challenge. James Randi has 1.000.000 dollars waiting in a bank account for anyone who can demonstrate that he/she has psychic/supernatural powers. Hundreds have tried but no one has succeeded until this day. Others, including the previously mentioned Houdini, and the Swedish organization Humanisterna have posed similar challenges. (Just recently, a psychic in Sweden failed a mutually agreed upon test, getting zero correct of a possible fifteen.)

Through the years James Randi has appeared on TV quite a few times. If you go to "You Tube" and search for James Randi you will find many interesting clips to watch. Alternatively, you can also go to his website, http://www.randi.org/, where there is a nice collection of multimedia as well as many interesting articles.

Below I have put together my own list of my favorite Randi multimedia including some personal comments. Enjoy!

Uri Geller and Peter Popoff. In this video Randi explains what he is doing and why he is doing it. Randi also shows how he exposed Uri Geller (see picture), the spoon bender phenomenon for what he really is, a fake (or perhaps he really just had a bad day). Finally he shows how Peter Popoff, a priest who makes miracles happen, was actually just using a wireless radio (Popoff went bankrupt a year after he had been exposed).

James Hydrick. James Hydrick, a 23 year old martial arts trained psychic, claims that he can turn pages the pages of a phone directory using his mental powers (and that we all can learn to do it). By using a simple control Randi shows that Hydrick is not using any psychic powers, but rather he is simply blowing. According to wikipedia, Hydrick has subsequently admitted that he was indeed a fraud, what a surprise…

Astrology. An entire class is given identical horoscopes and are asked to rate the accuracy. Everyone in the class rates the accuracy as being either four or five out of five.

Psychic surgery. In this video Randi performs, using only his bare hands, what looks like a very real surgery in order to show that no supernatural powers must be involved (as some others have suggested)

Homeopathy. This video is actually one of my favorites. Randi has a 15min lecture in which he explain the very odd principles of homeopathy. He also tells us about when he downed no less 64 tablets without being affected at all. This is despite the fact that that the cans say that you should call a poison doctor if you take 4 or so (I cannot remember the exact numbers).

Spoon bending. Randi shows us how he can bend a spoon using trickery. It looks just like when Uri Geller bends his spoons using his psychic powers, or perhaps Geller was also using trickery? You decide…

Medium discussion, Part 1, Part 2, Part 3. Randi is on Larry King live where he discusses an incident where the medium Sylvia Browne told the parents of an abducted child that their child was dead. The women who got the erroneous information from her spirits still claims to have psychic powers, she have accepted Randi challenge, but have still not actually done it. Afraid that she won't make it perhaps?

James Randi and a medium. In this video Randi exposes a medium by revealing a transcript in which the medium has given her client no less than 37 names, and asked him whether he feels there is any connection to any of these names. Statistically speaking it would be quite unlikely if the client had no connection to any of the names...

Applied Kinesiology. In this video James Randi, and a kinesiologist do a blind study, testing whether a particular chosen crystal make the test person stronger. If you are to believe the result in this particular test, the subject benefitted very much from rat poison, hmmm...

If anyone has any further multimedia tips I will watch them with much interest.

Evidence suggesting that there might be something to homeopathic remedies, and why I am still not convinced

In a previous post I have explained why I do not believe homeopathy works. To demonstrate how fair and objective I am =), I thought I would write about the so called “Belfast homeopathy results” (see citation below). These results have become famous because they show that a substance which once contained histamine-like molecules, but which have been diluted so much that there is almost not a single molecule left, still works like histamine. In essence this means that pure water can produce the same effects that histamine produces. Furthermore, the study has been replicated three times. Ennis, the investigator (see picture), seems to be just as puzzled as I am about this. If the experiment was indeed sound in all respects, then the findings are truly revolutionary.So why am I not convinced?

Before saying why I am not yet convinced I want to emphasise that I do not think there is any bogus here. I believe Ennis (unlike many others who do similar studies) is a serious researchers, and that her results should not be ignored. The reason I do not buy it is that it contradicts so much of what we know, or think we know. If there is something to the basic laws of physics and chemistry that we have found and that our society is based upon, then the conclusions drawn from Ennis study cannot be right. I see it as much more plausible that there is some methodological flaw in the experiments. I mean, is it more likely that in spite of everything we know, our world is not really made of atoms. Or is it more likely that one researcher has a flaw in the experimental design? I will go for the second option, but I suppose I could be wrong.

My scepticism is further reinforced by the fact that many previous studies testing homeopathic substances have returned negative results. In fact, as a general rule, the better the experiment, the smaller the probability of positive results. You can read about a follow up experiment that was done to check the validity of Ennis results here. Here Horizon magazine took upon the challenge and tried to replicate Ennis results. They even had the chance of getting a one million dollar award from James Randi foundation, should they succeed. The experiment failed.


Citation:

“MADELEINE Ennis, a pharmacologist at Queen's University, Belfast, was the scourge of homeopathy. She railed against its claims that a chemical remedy could be diluted to the point where a sample was unlikely to contain a single molecule of anything but water, and yet still have a healing effect. Until, that is, she set out to prove once and for all that homeopathy was bunkum.

In her most recent paper, Ennis describes how her team looked at the effects of ultra-dilute solutions of histamine on human white blood cells involved in inflammation. These "basophils" release histamine when the cells are under attack. Once released, the histamine stops them releasing any more. The study, replicated in four different labs, found that homeopathic solutions - so dilute that they probably didn't contain a single histamine molecule - worked just like histamine. Ennis might not be happy with the homeopaths' claims, but she admits that an effect cannot be ruled out.

So how could it happen? Homeopaths prepare their remedies by dissolving things like charcoal, deadly nightshade or spider venom in ethanol, and then diluting this "mother tincture" in water again and again. No matter what the level of dilution, homeopaths claim, the original remedy leaves some kind of imprint on the water molecules. Thus, however dilute the solution becomes, it is still imbued with the properties of the remedy.

You can understand why Ennis remains sceptical. And it remains true that no homeopathic remedy has ever been shown to work in a large randomised placebo-controlled clinical trial. But the Belfast study (Inflammation Research, vol 53, p 181) suggests that something is going on. "We are," Ennis says in her paper, "unable to explain our findings and are reporting them to encourage others to investigate this phenomenon." If the results turn out to be real, she says, the implications are profound: we may have to rewrite physics and chemistry.”

From issue 2491 of New Scientist magazine, 19 March 2005, page 30


End of citation

The placebo effect

As far as I can remember I have always been opposed to, or at least skeptical towards the use of medicine that has not been properly tested and compared to placebos . I think that medicines should be tested extensively before they are released on the market. If you will, I am a bureaucrat in these matters, but why? Before I dwell further into this it is probably good with a definition of the placebo effect, here is one:

"A physical or emotional change, occurring after a substance is taken or administered, that is not the result of any special property of the substance. The change may be beneficial, reflecting the expectations of the participant and, often, the expectations of the person giving the substance."

But this sounds great does it not? If this is true then we can stop all administration of conventional medicine and thereby avoid all the associated side effects. As long as we can convince patients that water will heal them, it will, right? Just as a parenthesis, I think this is how homeopaths achieve their results. They are after all administering water with no active substance left in it.

The problem with a heavy reliance on placebos is that people would have to have a certain state of mind in order for a placebo to have any effect. Perhaps it is possible to create this state of mind by saying, for instance, that water will cure whatever it is the patient is suffering from. However, if this deception became a standard medical procedure I think that in the end people would cease to believe the doctors and then the placebo effect would disappear, and we would have no effective cures. Now some will probably object and say that it is not deception, but I think it is. If they were honest they should say that the medicine might have an effect, depending on whether you believe in it or not, and that is different. Similarly, if doctors would, on a large scale, tell their patients that they were getting for instance Prozac when in fact they were only given sugar, then this scam would eventually be detected and people would start to distrust their doctors which would diminish the placebo effect. In sum, apart from requiring doctors to lie to their patients, using placebos on a large scale would only achieve results for as long as doctors were able to keep their deception in the dark.

In the above I have tried to reserve some space for a few positive words. It should be clear by now that placebo effects are dependent on the state of mind of the person taking the placebo, it is not an intrinsic property of the substance that is taken. This means that certain therapies, such as for instance homeopathic medicine, will work on some people (probably those who believe in it) but not on others. Thus if we were to analyze the set of beliefs that a particular patient has then it should be possible to give that patient whatever he or she believes in and achieve an effect. In essence I am saying that if someone believes that acupuncture will achieve miracles, then give them acupuncture, or if someone thinks that homeopathic medicine is good against headaches, then, by all means, give them their homeopathic substances. However, because the placebo effect is rarely as strong as the effect of conventional medicine, I think this approach should be confined to less serious conditions.

I see one further application or lesson from the above. I think that doctors should do their best to encourage their patients. Make them feel good, and tell them that they can help themselves in the healing process (not a lie). I think that a lot could be achieved by giving patients a sense of their intrinsic ability to heal themselves. The first essay I wrote at Lund University was about this. If you are interested you can read it here.

The cruelty of male circumcision

Today it is quite unthinkable to question the cruelty of female circumcision if you are a relatively informed person. However, to my own amazement, male circumcision (see picture) is still considered by many to be perfectly justified. It must evidently be so, considering how often this surgery is performed on young naive infants.

At one point in my life I actually became a little bit ambiguous as to whether circumcision might perhaps be justified. It was last year when, during my exchange year at UCSB, I attended some highly entertaining and informative lectures on Human Sexuality taught by two very charismatic (and married) professors John Baldwin and Janice Baldwin. You can read more about the Baldwins' view on circumcision here. I am not being ironic when I say that these were indeed great lectures, and that is perhaps why they almost convinced me that the costs and benefits associated with male circumcision more or less cancels out. As far as I can remember they referred to two positive consequences associated with male circumcision. One is the supposedly improved hygiene, which by the way is one of the most common justifications that people in favor of circumcision refers to. However, bad hygiene under the foreskin is only a problem for guys who never clean under the foreskin, so if we would simply remind guys that they need to remember to clean their more private regions this would not be a big problem. In any case I hardly think that this justifies circumcision….

The other favorable effect of male circumcision, the one that made me think that perhaps it was justified, is the reduced risk of being infected with the HIV virus. A few studies of this kind have been made and the effects superficially seem quite large. However, the studies which have shown this difference have been of poor quality, with poor control. Just as an example, in one large and frequently cited study, circumcised males were given advice on sexual behavior whereas those who had not been circumcised did not get this offer. Was the lower incidence of HIV among the circumcised due to the sexual advice or the circumcision? Studies with better control i.e. studies which try to rule out alternative explanations, have found smaller effects (see here for more information). I will not go as far as to say that circumcision does not give any improved protection at all, on the contrary, I believe that there is some truth in this. Nevertheless, it seems that the effects are significantly smaller than what the original studies suggested.

The fact that there seems to be no great benefits of circumcision is however not my main problem with it. Neither do I dislike it just because it is very much entangled with religion. I think it is a good example of how religious beliefs sometimes takes the upper hand over rational arguments, but it is not the main reason why I disprove of male circumcision. So what is the main reason? The reason is that the foreskin, which is removed during a circumcision, has a lot of very important functions. I think that this is hardly surprising because if the foreskin had been completely useless or even a burden to us, natural selection would probably have taken care of it long ago. The benefits of having a foreskin are many. To name a few, the foreskin is important because it gives protection to the glans penis, it reduces friction during intercourse, it gives important feedback to our brain about the "state" of the penis, it aids erection, and it regulates the timing of the ejaculation (people who have been circumcised often either ejaculate too early or too late). You can read about these as well as other function of the foreskin on this excellent page.

However, I think that the most important function of the foreskin, and hence also the most important reason why circumcision should not be allowed, is that it brings sexual pleasure to its owner. This of course also means that lack of foreskin will result in reduced pleasure. Sex, along with drink and food and neuroscience (that last one is probably rather personal), are things that make life worth living, and taking away the pleasure associated with sex just seems rather cruel to me. Now I am not saying that circumcised people do not feel any pleasure, I would not know, all I am saying is that there is good reason to believe that they feel less pleasure.

Summing up, besides just being a nasty and invasive surgical procedure which could well cause some kind of trauma in the infant, taking away the foreskin is associated with many other disadvantages. Even if the risk of contracting HIV would be slightly reduced, this hardly justifies circumcision.

True cyborgs now a reality!

Muscular movements are controlled by the central nervous system. Right now my brain is actively planning the muscular contractions that will make my fingers exert a force on different buttons on my keyboard, ultimately resulting in the text that you are hopefully enjoying right now. How does this work? Well, there are many unsolved mysteries, but we have also learned quite a lot.
Two areas of the brain, the "supplementary motor area" (SMA) and the "premotor area" (PMA), seems to be involved in planning the exact series of muscle contractions that are required in order to do something such as writing this text. How do we know this? Put a person in an fMRI machine and ask them to imagine doing something, and wallah, SMA and PMA lights up (meaning that more blood is going to these areas, mening that more glucose gets there, meaning more activity in those cells)! In order to actually move you will also have to get your motor cortex involved. It is from this area that axons travel down into the spinal cord and elicits movements. If you stimulate the motor cortex electrically during a surgery (this is sometimes done to see how the body is mapped onto the motor cortex), then the corresponding muscles will contract, perhaps resulting in an arm or a leg flapping out. So when your SMA and PMA have planned the contractions they will communicate with the motor cortex which then sends signals down to the alpha motor neurons in your spinal cord which in turn will release acetylcholine onto the muscles causing them to contract. All this happens within a few milliseconds! (Of course other areas such as the basal ganglia and my own darling, the cerebellum are also involved in movements, this was merely a simplified account.)

Who cares?, where are the applications? Back in 1982 a guy named Georgopoulos measured the activity in the motor cortex of a monkey while it was performing some well defined motor tasks. Georgopoulos found that a certain movement would be associated with a particular pattern of activation in the motor cortex. Thus, merely by looking at the activation in the motor cortex he could predict that the monkey was trying to move say, its left index finger. This could be very useful for people suffering from paralysis. Theoretically it should be possible to measure motor cortex activity and from that see what movements the motor cortex is trying to do. Then, to help a paralysed patient what you need to do is to connect a robotic arm programmed to move in response to neuronal activity. This procedure is no longer science fiction, it is reality. In this article it is described how some surgeons used signals coming from the motor cortex to make a prosthetic arm move, in other words they made a true cyborg out of lucky Mitchell, 24.

Although I am pessimistic about the prospect of creating a brain that is as complex as our own I do think that in the future more and more applications like this one will appear.

New international guidelines for stem cell science

I have just had an interesting discussion with "anonymous" about the ethical issues associated with stem cell research. Yesterday I saw that an organisation called International Society for Stem Cell Research (ISSCR) have released a document in which they spell out some ethical guidelines. You can read about it here. ISSCR, controversially, states that they think it is okay to pay women to donate eggs. This has been largely prohibited before. Their argument is that the money in itself is only an issue if women start to ignore risks because of the gain.

“What you need to focus on is not the amount of money changing hands, but rather how the financial consideration is affecting the decision the woman goes through,” Daley says. “If it would make [the potential donor] trivialise any of the risks then it constitutes an undue inducement.”

A private reflection is that medical testing would come to a complete stop if money were not paid to subjects. Who would want to go to Astra and have something injected for fun? I have myself considered taking part in pharmacological studies because you get well paid and only expose yourself to low risks. I don´t think I would do it for free however. I do not really see the difference between the two examples. Of course it would be a problem if women ignored their own health and started to make a living out of donating eggs, however, it would also be a problem if they made a living from taking part in medical trials.

I think that rather than prohibiting payments, we should try and make sure, as far as possible, that women do not start to make a living out of donating eggs, hard as that may be. We should also keep in mind that stem cell research probably is our best hope when it comes to curing some of the worst diseases out there...

The difference between science, faith and religion

I am sure everyone who have been reading this blog occasionally will know by now that I am a science freak. I think that science is the way to gain knowledge. Many people say that science is narrow minded, that believing in science will confine the scope of our knowledge, but I disagree. Science, for me, is an open minded and modest approach when it comes to discover new things. Science is based on evidence. However, evidence is not necessarily gathered in a laboratory by people in white lab coats, evidence can be all sorts of things. As defined by oxford concise dictionary, evidence is "the available facts, circumstances, etc. supporting or otherwise a belief, proposition, etc., or indicating whether or not a thing is true or valid".

So what does not count as evidence you might wonder. My own answer to this, which I have not thought so much about, is things that can just as well be explained by chance. Often, when I discuss homeopathic medicine or other alternative approaches to medicine, I hear statements such as "well look, person x got well after taking this medicine, you see, it works". Perhaps this could be seen as evidence, but if so, it is one of weakest forms of evidence. Why? Because person x could have gotten well for any number of reasons, after all our immune system will deal with almost everything in a relatively short amount of time. I would take any type of medicine seriously, including homeopathy, if they could show in a double blind experiment that it worked.

Science is not the same as faith which is defined in my dictionary as "complete trust or confidence", or "firm belief, esp. without logical proof". As I have just shown it is almost the opposite. My ideal is to be sceptical to ideas with weak evidence, but not so sceptical that I cannot be convinced when proper evidence does exist.

Science is also different from religion which in my dictionary is defined as "the belief in a superhuman controlling power, esp. in a personal God or gods entitled to obedience and worship". Science is a method (or rather a gizillion methods) to achieve knowledge. Religion, on the other hand, is a belief in a superhuman nature, they are completely different concepts. A minority of scientists are religious (Einstein, by the way, is not one of them), the majority is not. The two are in other words more or less independent of each other. This is not entirely true of course since by scientific standards, religion is a weak theory with a minimal amount of supporting evidence. For this reason I am an atheist, but again, if proper evidence is shown to me I would change my mind.

I want to end with a great quote by Carl Sagan that I just read and which captures most of what I have written here; "Be open-minded, but not so open-minded that your brains fall out."

Why I don´t believe in homeopathy

Homeopathy is an alternative kind of medicine based on the principle "like cures like". This means that a substance which in a large dose will cause some form of illness, will in a small dose cure the same illness. Already at this point my sceptic instinct kicks in. Does this mean that if I am poisoned with arsenic, then taking a little bit more will cure me? Eating fat food (in small quantities) will make me thinner? Sugar will help against diabetes? Furthermore, it is suggested that substances get better the more diluted they are. One explanation of this pattern could be that the active ingredient is harmful, and therefore, the more diluted substance will have less of a negative effect on the patient. Often homeopathic medicines doesn´t contain a single molecule of active substance, it is pure water. It is claimed that the water molecules have a memory of the active substance and therefore they work (see picture). I would like to know how a memory is stored in two hydrogen and an oxygen... Despite these issues which are at odds with both chemical and physical principles homeopathic medicine is gaining in popularity. In Belgium, for instance, 52% of the people use homeopathic substances. On the positive side, these substances are unlikely to do any harm to the patients.

Since I grew up in Järna, the Scandinavian centre of the Antroposofic movement, I have been exposed to many weird theories that flourish in this little town. I should mention here, in case friends and family read this, that I think there are many good things about antroposofi. They have a developed art and many good artists have received their training in Järna. I also think their school system is superior to others in many respects (though not all). Nevertheless, some theories are, in my opinion, swallowed with too little sceptic though. For instance, in Järna people widely believe in astrology, and they use celestial powers to make biodynamical foods that will give the consumer more spiritual strength...

In Järna it is also widely believed that homeopathic medicine works. My mother is one of its advocates and she often gave me these substances when I was sick. When got well she would say, I told you so, it works. I don´t think she thought a lot about it when I followed the normal pattern. Individual exemplars are of course no valid evidence, even if I did get well earlier than normally it might have been because of other factors, such as the healthy food that she insisted on giving to me (which I am of course grateful for). So what does the evidence say?

There are, to my surprise, one meta-analysis which suggests that homeopathic substances do have an effect. This study, published in the British medical journal showed that in 81 out of 107 trials, homeopathic substances had been effective. However, in another meta-analysis published by the lancet, the effect was at par with the placebo effect. Studies with better experimental control more rarely show significant effects. Because homeopathic theory is at odds with chemical and physical laws I believe that the effects that are attributed to these substances are actually placebo effects.

A clever little twitch has made it all but impossible to falsify homeopathy, which is not a virtue in a scientific sense. Homeopaths claim that even though two persons have the same disease, they may need different remedies, so when someone is given a homeopathic substance and there is no effect, the doctor can simply refer to this principle. This is similar to telling your psychoanalyst that you were not abused as a child. He (it is normally a he) will respond that you are in denial. If you say that you were indeed abused he will say "aha, then I was right"...

There is an award of one million dollars to you if you can show in a well conducted experiment that homeopathic medicine works...

South Africa finally starting to realize what AIDS is…

Each time I have read about AIDS policies in South Africa I have been amazed. South Africa is, as far as I know, a relatively developed country if you compare it to other nations in the same area, yet somehow they have managed to avoid reading about AIDS research for at least a decennium. Only a few years ago president Mbeki (picture) questioned whether HIV and AIDS were related(!). Since then his unbelievable ignorance has generated headlines on a regular basis. On one of his particularly bright moment Mbeki said that he did not know anyone who had died in AIDS. Not long before he uttered these words his own press secretary had succumbed to the disease, not to mention the 600 people who die from AIDS in South Africa every single day!

The climax happened in august this year when South African representatives visited the international AIDS conference, proudly exhibiting their best cures against the disease, such as beets and garlic. They were severely ridiculed because of this, and a speech by AIDS activist Stephen Lewis (who is by the way not welcome in South Africa) received wild cheers when he described South Africa’s AIDS policy as insanity (I would have clapped to). Since then South Africa, thank god, have started to give their population conventional medicine which can help increase life span as well as life quality. Out of the 5.5 million HIV carriers in South Africa today, 213000 are receiving medicines, a figure which is currently increasing with 11000 per month. Too slow indeed, but better than it has been before.

What I really find hard to understand about all this is why? What do politicians have to gain by letting their people suffer more than is necessary? Does anyone know? Or is it really true that they believe Garlic and beets (or having sex with infants) really helps? Do religious beliefs play a role? In all fairness you can find weird cures for most things in most countries, but rarely does the government itself hold such outrageous beliefs about such a serious belief…

Most of this I read in yesterdays (14^th of December 2006) issue of In yesterdays Svenska dagbladet.

Our debt to research animals...

If you google for "animal research" and then switch to the pictures section you will see many very upsetting pictures depicting animals that have been used in research. I first want to point out that these pictures are not representative of the way it looks in most laboratories. Secondly, the animals in the pictures may not have suffered to anywhere near the extent that people uploading these pictures want to make you believe.

I do not think that being a laboratory animal is a great life for an animal, however, nor do I think that it is the worst fate an animal can suffer. I would personally much rather be a laboratory rat than a cow or a chicken that is slaughtered to become food for us. There are a number of reasons why animal research is not as bad as some people want us to believe. First of all, only in a minority of all the conducted experiments do the animals experience any pain, and when they do they are nearly always given anesthetics (one exception to this is when pain is the research subject in which case it is a necessary evil). Secondly, researchers, in order to get good data, must make sure that their animals are feeling well. Data from sick laboratory animals is worthless. Of course, the well being of laboratory animals is also inspected by committees on a regular basis and labs which do not take proper care of the animals will be shut down. Thirdly, for me, personally, working with laboratory animals actually made me value animals more than before. Rats are, believe it or not, smart playful and social, and working with them have made me more concerned about animal welfare in general. I now buy ecological meat, eggs from free outdoor hens (free walking indoor is no good either!), and in general try to buy products that have not caused unnecessary pain for any animals. This brings me to my next point.

I often hear from different people that many animal experiment that are carried out are unnecessary. To some extent I agree, I think that animal experiments that are done to develop new cosmetics are definitely unnecessary, let us use what we have got and spare these animals. Nevertheless, to conduct an experiment involving animals at a university one have to argue, very convincingly, that the research can further our knowledge in some way, and one must justify any hypothetical pain that the animals must endure. It is also not true that there are other methods that we could use just as well as animal research. Sure, studies can be done in vitro (that is, in a dish), but today these methods cannot replace animal research.

In the end I guess it all comes down to what your values are. Is it worth it to sacrifice laboratory animals in order to develop medicines that can cure us as well as animals. My answer is yes, but I don't think it is entirely obvious, so think for yourself. Perhaps we should be content with just living 48 years instead of around 75 years, and perhaps we should just accept that some diseases will kill us (I am not being sarcastic here).

I want to end with a list of some of the discoveries that would not have been possible was it not for animal research, you can find a much longer list and more information about animal research here. Our dept to laboratory animals, as you can see from the list below (remember this is not a complete list), is indeed great. The laboratory animals have helped us alot, and for that they deserve our respect, but should we stop doing these types of experiments?

Vaccines: Anthrax, Smallpox, Polio, Yellow fever, Measles, Hapatitis, Whooping cough...

Drugs: Insulin, Antibiotics, Birth control pills, pain killers, anti malaria drugs, chemotherapy...

Treatable conditions: Anemia, PKU, Herpes, Allergies, Chlamydia...

Life prolonging treatments: Diabetes, Epilepsy, Leukemia...

Other major discoveries: DNA, Virus, Electron microscope, ECG, EEG, Pacemaker, Artificial hips, x-rays, monoclonal antibodies, ultrasound, MRI, Artificial limbs, Effects of smoking alcohol and drugs, How lifestyle affects health

Surgery: Blood transfusions, Coronary bypass, Organ transplants, Breast cancer

Should we use stem cells?

"Stem cells fend off lung cancer".

I just read a news article with this headline in the journal Science. Apparently, because stem cells are rather similar to cancer cells, the immune system adaptation that occur when you inject stem cells into the lung, will subsequently help the immune system kill cancer cells as well. That is, the immune system treats stem cells as invaders, why they develop a defense against these cells. If the same immune system, on a subsequent occasion, encounters a cancer cell it will, because of the strong resemblance, wrongly "assume" that it is another stem cell and therefore get rid of it. Out of 25 mice that were given stem cells, 20 were able to kill a subsequent cancer. A slightly altered compound increased the cancer survival rate to 100%!!! This should be compared to the 0% survival rate experienced by mice that did not get any compound.

Of course, this does not mean that we can cure cancer in humans, at least not yet. Mice for some reason tend to respond better to cancer therapies, but nevertheless, I think the figures above justifies some excitement. I think that stem cell research is one of the methods with the best potential. This research not only has the potential to cure cancer, but various other diseases and insults as well, including Parkinson disease, chronic pain, and strokes.

So what about the larger issue? Are stem cells individuals? I guess that if you believe that a cell with all the genes necessary to build a human being is an individual, then stem cell research is murder. However, if this is your belief then scratching your nose or stepping into a shower would be genocide. All the cells that die when you do one of these two things could produce an individual if you put it into an egg and allowed it to mature. So why should stem cells be protected as if they were full grown individuals? A fully conscious monkey, capable of feeling pain and stress, has barely any rights! That is puzzling to me. Furthermore I think not doing stem cell research is unethical, considering the huge potential. Not doing stem cell research is the same as saying to those who have Parkinson or those who are suffering from chronic pain, that "we care more about these few cells than we care about finding a cure for you".