Trump's budget proposal eviscerates biomedical research, for no good reason

Donald Trump proposed a budget this week that will cut funding to NIH by nearly $6 billion, or 20% of its $31 billion budget. A cut of this magnitude would be devastating for biomedical research, and for the health of the nation.

This is colossally short-sighted, stupid, and even cruel. The U.S. budget this year is $4.0 trillion, which means that the entire NIH budget is only 0.75% of the budget. A 20% cut to NIH, while incredibly damaging to medical research, would only reduce expenditures by 0.15%.

Besides being shortsighted, this proposed cut is heartlessly cruel. What diseases, Mr. Trump, do you want people to die of? Should we halt research on aging? (Not a good idea for 70-year-olds like you.) How about cancer, or diabetes, or infections, or schizophrenia, or heart disease, or lung disease? Or maybe Trump wants to eliminate the NIH Children's Inn, where desperately ill children stay while receiving treatments. The list is very long; NIH supports work on 265 diseases and health conditions.

Everyone who is reading this either already benefits from medical research, or will some day.  Even if you are in perfect health, someone close to you probably uses a treatment that was supported by NIH. Virtually every major medical center in the United States depends on this funding. There are few investments with broader impact, and broader public support, than biomedical research.

For those who want to look at this from an economic perspective (as I explained in 2013), NIH funding is a terrific investment. A nonpartisan study in 2000 concluded that:
"Publicly funded research generates high rates of return to the economy, averaging 25 to 40 percent a year."
That's an amazingly good investment. The same report provided detailed examples showing how NIH-funded work saves billions of dollars per year in health care costs. But keep in mind that most of these benefits don't appear for many years. The private sector simply won't make such long-term investments.

On a more mundane level, NIH generates thousands of jobs in states all across the nation. If you want to see how it affects your state, check out this graphic from United for Medical Research. Do you live in Ohio? NIH directly supports over 11,000 jobs and $670M in funding, affecting 2,500 businesses in your state. Florida? Another 11,000 jobs, $520M in funding, and over 5,000 businesses. Texas? 21,000 jobs and over $1B in funding. And so on.

Does Congress want to kill NIH? I seriously doubt it. Does Donald Trump? I'm just speculating, but I think the ansswer is no. I think Trump doesn't understand what NIH does, but that someone in his inner circle–someone with a wildly distorted worldview–has inserted his own warped ideology into the President's budget proposal.

Finally, what's the motivation for these cuts? The U.S. economy is doing quite well, far better than it was in 2008 when Obama came into office. The economy then was in a devastating recession, but we didn't implement drastic cuts then, and we climbed out of it. We've had low unemployment and steady growth for years. It's not clear we need to cut the budget at all, much less make draconian cuts that would eviscerate and eliminate enormously beneficial programs. And if Trump wants to reduce spending, it makes no sense to cut programs that collectively only represent a tiny part of the total. One can only conclude that Trump's proposed budget cuts are entirely ideological, not financial.

Fortunately, budget making authority in the U.S. rests with Congress, not with the President. Let's hope that Congress will ignore this shortsighted, cruel, and pointless proposal to cut medical research to the bone, and instead will continue to invest in what is, for now, the strongest biomedical research community in the world.

The new EPA Chief is a climate denier: why are you surprised?

On Thursday, newly appointed EPA chief Scott Pruitt said he doesn't think human-driven carbon dioxide emissions cause global warming. The internet exploded with outrage.

Why so surprised? We already knew that Scott Pruitt was a climate change denialist.

Donald Trump is also a climate change denialist. Why is anyone surprised that Trump is appointing other denialists to top posts in his administration?

During his campaign, Trump claimed that climate change was a "hoax" perpetrated by the Chinese. Mr. Trump just made that up: it's complete nonsense, and he would be laughed out of the room in a serious discussion of climate science. Unfortunately, he now has too much power for us to ignore him.

The Secretary of Energy, former Texas governor Rick Perry, has also been a climate change denier, although he "softened" his position during his confirmation hearings. At those hearings, Perry said
"I believe the climate is changing. I believe some of it is naturally occurring, but some of it is also caused by man-made activity." [Secr. of Energy Rick Perry]
How refreshing! What really matters, though, is whether we'll Perry's newfound awareness will be reflected in actual policy, or whether it was just a pose he adopted for the hearings.

Scott Pruitt, though, is unreprentant. Pruitt has spent much of his recent career suing the EPA on behalf of oil companies (despite the fact that he worked for the state of Oklahoma, not for those companies). Oil companies, coal companies, and others who make their money from fossil fuels–notably the Koch brothers and their fake-science-pushing Heartland Institute–have devoted millions of dollars and years of effort to climate change denialism. We already knew Scott Pruitt was one of them.

On CNN, Hawaii's Senator Brian Schatz commented:
"If there was ever any doubt that Scott Pruitt is a climate denier, this settles it."
Sen. Schatz is correct, of course–but there wasn't any doubt in the first place.

The New York Times couldn't have been surprised. Just two days before Pruitt's on-air denial, they ran a story headlined "E.P.A. Head Stacks Agency With Climate Change Skeptics." The Times pointed out that Pruitt's chief of staff and top deputies are former staffers of Senator James Inhofe, one of the Senate's leading climate change deniers.

I do have a major disagreement with The Times, though: stop calling these people "skeptics." They are not skeptics. A skeptic is someone who insists on solid evidence before accepting claims about science, medicine, or other fact-based issues. Once evidence is produced, a good skeptic acknowledges the evidence and changes his/her views, if necessary.

Denialists, in contrast, stick to the same rigid narrative regardless of the facts. When evidence contradicts their views, they have no choice but to deny, deny, deny. When pushed, they obfuscate and delay, often arguing that the evidence is not yet clear and more studies are needed. This is precisely what EPA head Scott Pruitt and his boss, Donald Trump, have been doing with climate change. Pruitt argued on Thursday that "we need to continue the debate and continue the review and the analysis." No, we don't. The evidence is overwhelming that the planet is warming, that rising CO2 emissions are a major contributor to that warming, and that human activities are causing much of it.

The Intergovernmental Panel on Climate Change (IPCC), summarizing the work of thousands of scientists from around the globe, has concluded with very high confidence that human activities are the primary driver of climate change. They've also explained (hello, Scott Pruitt?) that carbon dioxide is the most important human-driven cause of global warming, and that it has increased 80% since 1970.

Because Scott Pruitt is a denialist–not a skeptic–he will simply deny these facts.

The New York Times and other media need to stop calling Pruitt a skeptic. Skepticism can be healthy; all good scientists are skeptics. Denialism, on the other hand, can lead to great harm. Cigarette companies were not being skeptical when they denied, for decades, that cigarette smoking causes cancer. They too called for more research. They were protecting their profits, and millions of people died while the companies denied and delayed.

Oil and coal companies are now playing exactly the same game, sowing doubt in order to preserve their profits. Scott Pruitt demonstrated this when he claimed, on CNN, that "there's tremendous disagreement about the degree of impact [of human CO2 emissions]." No, there isn't. Quite the opposite is true: there's remarkable agreement among climate scientists that humans are causing global warming. The only source of disagreement is the profit-driven fossil fuel industry, which cares far more about its short-term profits than about the world that future generations will inherit.

So let's not be surprised when Trump and his minions deny climate change, or deny that human activities are causing it. Perhaps it would be better to consider what the harms will be, and whether we can prevent them. Just don't expect any help from the government.

Don't do this: 150 medical practices that all fail, especially acupuncture

This is ineffective - and cruel.
Why do people keep doing things to their bodies that don't work, and that even hurt them? This seemingly self-destructive behavior is what allows bad medicine to thrive. One problem is that people are easily fooled by self-interested con artists selling snake oil: homeopathy and acupuncture fall into this category. Another problem is that even doctors can be fooled, especially when a practice seems to make sense.

One great example of this is stenting: the use of a small, flexible tube to re-open and hold open clogged arteries. This seems like such a reasonable idea–if a pipe is clogged, unclog it and put something in there to keep it clear. And it does work, sometimes, but the evidence shows that for people with minor blockage, it usually does more harm than good. A new article in The Atlantic, "When Evidence Says No, but Doctors Say Yes", explains that in a recent 5-year period in the U.S., "about half of all stent placements in stable patients were either definitely or possibly inappropriate," as shown in a new study. The authors also point out that stenting remains the go-to procedure for any patient with clogged arteries, even among physicians who have read the studies. The problem here is that stenting just seems so darned logical.

At least stents work some of the time. What about procedures and medications that don't work at all, and that sometimes cause harm? Five years ago, a team of scientists in Australia conducted a massive review of evidence for thousands of medical practices, and found 156 that either don't work or actually cause harm. Their list of ineffective and harmful procedures should be required reading for anyone who is considering a medical procedure.

I can't go through all 156 bad practices, but one group of procedures stands out as particularly ridiculous (by which I mean the original sense of the word, "deserving of ridicule"). These are the various uses of acupuncture, all of them ineffective, none of them with even the slightest plausibility, but all of them promoted by quacks acupuncturists. Here they are–and remember, each of these has been tested scientifically and shown to be either useless or, even worse, harmful:

  1. Acupuncture for women in labor. From the study: "In the absence of sufficient evidence that proves either effectiveness or harm, acupuncture as a method of induction is not recommended."
  2. Acupuncture for uterine fibroids. "There is no reliable proof of effectiveness of acupuncture for uterine fibroids." (Aside: if a woman has fibroids, multiple options are available, many quite effective. The claim that acupuncture might treat them is patently ridiculous.)
  3. Acupuncture for irritable bowel syndrome. Studies have found "no significant effect of acupuncture on IBS global symptoms, pain, and quality of life compared with placebo." 
  4. Acupuncture for otitis media with effusion (fluid in the middle ear). This condition is common in children, and acupuncturists are only too happy to plunge their needles into unsuspecting kids. The study found no evidence that this works, and concluded that "acupuncture should not be used for the management of patients with OME."
  5. Acupuncture for lower urinary tract symptoms in men. This too doesn't work. I wonder where they stick the needles?
  6. Acupuncture to treat hyperbilirubinaemia. This condition, commonly known as jaundice, is often seen in very young infants. The suggest that we treating babies with acupuncture is, frankly, primitive and terribly cruel. The study concluded starkly that "there is no evidence to support the use of acupuncture to treat hyperbilirubinaemia–NICE recommends that this treatment not be used in this population." (NICE is the Australian National Institute for Health and Clinical Excellence.)
  7. Laser acupuncture for carpal tunnel syndrome. Multiple studies found that acupuncture doesn't work for this either. One study concluded that "more rigorous studies are needed." Why waste more time on this hopeless pursuit?
  8. Acupuncture for depression. Lots of studies, most with a "high risk of bias," and all of them finding that acupuncture doesn't work for depression. This is depressing.
  9. Acupuncture for osteoarthritis. Not surprising, acupuncture for arthritis is no better than placebo.
  10. Acupuncture for Bell's palsy. Eight trials, none of them showing any reliable benefits. Subject patients to more of these trials would be cruel and unethical.

So there you have it: 10 out of the 156 bad medical practices involved acupuncture. If you want to see the rest of the list, check out the full study. As for acupuncture, this is by no means a complete list of the claims that acupuncturists make. Indeed, just last week a new study claimed that acupuncture helps treat migraines, prompting a rebuttal from UC San Francisco's Amy Gelfand, in the same journal, saying no, it doesn't. (Dr. Gelfand explained a lot more than that, but I'm summarizing.) The pro-acupuncture study was done in China, where virtually all acupuncture studies report positive results, and the lead author works at the Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine.

We should all thank Drs. Elshaug, Watt, Mundy, and Willis for their tireless effort in reviewing thousands of studies, so that the rest of us don't have to. Acupuncture studies will keep appearing, but there's no reason to believe anything new will emerge. It's time for people to stop fooling themselves about this particular brand of pre-scientific pseudoscience.




World's cutest mammal critically endangered because of Traditional Chinese Medicine


A pangolin. Photo (c) Christian Boix.
Pangolins, timid little anteaters that are covered with scales, are being hunted to extinction. Why? Because some humans think their scales can be used as medicine. Pangolin scales are made of keratin, the same stuff that makes fingernails and claws, and they have no more medicinal value than any other fingernails–which is to say, none at all.

Pangolins are gentle, toothless mammals that eat ants with their long, sticky tongues. They are covered with scales (sort of like a walking artichoke) which protect them from predators but not from humans, who simply pick them up to harvest them. Baby pangolins ride, adorably on their mothers' tails or backs, as shown in the picture here.
Photo by Firdia Lisnawati.

How could someone look at these creatures and want to kill them? And yet pangolins are being slaughtered in large numbers because some practitioners of traditional Chinese medicine (TCM) think (wrongly!) that pangolin scales can treat nervousness or palsy. They are also being killed for meat: regrettably, pangolin meat and fetuses are considered a delicacy by some people in China.

Just a few months ago, the CITES organization (Convention on International Trade in Endangered Species) banned trade in all eight species of pangolins. We can only hope that this blanket ban is not too late. Previously CITES had declared that Asian pangolins were endangered, but had allowed trade in African pangolins, but because the meat is indistinguishable, the limited ban did little to stop the widespread killing of Asian pangolins. Just before the CITES meeting, Annamiticus (@annamiticus) reported that in the first nine months of 2016, 18,670 tons of pangolin scales from 19 countries had been seized from smugglers, mostly in Hong Kong. And that's just the amount that was stopped; many more tons doubtless slipped through.

Despite the new CITES restrictions, trade in pangolins continues. In December, customs officials in Shanghai arrested 3 people who were attempting to smuggle over 3 tons of pangolin scales into China. That shipment alone represents 5,000 to 7,500 pangolins that were killed for their scales.

Next Saturday (18 February) is World Pangolin Day. Let's hope that the new CITES restrictions, and greater public awareness of the endangered pangolin, can save these gentle animals from extinction.

*note: perhaps it's not the "world's cutest mammal," but the pangolin is still worth saving.

Government scientists go rogue. What a great idea!

Government scientists are very worried, apparently with good reason, that their new boss wants to muzzle them. They've just come up with a brilliant strategy to circumvent this attempt at censorship.

Donald Trump and his minions have already made moves to suppress science within the government, with word going out that government employees cannot say anything to the public without the prior approval of political appointees. This has the marks of Stalinist (or should I say Putinist?) repression of free speech, not the sort of thing any of us ever expected to see in the United States. However, after running a campaign marked by outrageous anti-science claims on climate change and vaccine safety, Trump appears on track to use the enormous power of the federal government to suppress basic scientific facts.

Vladimir Putin has done the same thing. Most Russians think that Malaysia Airlines Flight 17, which was shot down in Ukraine in 2014, killing all 298 passengers, was shot down by Ukraine–despite the overwhelming evidence that the plane was shot down by a Russian missile provided to Russian-backed separatists by Russia. Putin had a record of suppressing, threatening, and even murdering those who speak out against him. Yet Donald Trump seems to find him the most admirable of all world leaders. And one of his closest advisors, Newt Gingrich, has said that he wants to fire all federal workers who didn't vote for Trump.

In just the past few days, though, government scientists have come up with a devilishly clever–and entirely legal–strategy to oppose the Trump administration's efforts to suppress their speech. Using Twitter, the same vehicle that Trump himself used so effectively throughout his campaign, they have created a set of "rogue" and "alt" accounts that have already started tweeting the real news about science, medicine, and the environment.

All of these accounts are run by non-government employees with no government sponsorship, but government scientists, in their off-hours time, can't be prevented from sending them information. In just a few days, these accounts have over 3.3 million followers, a number that is rising fast. Here's are some of the account with their total followers as of January 29:
Here are just a few of the tweets from these accounts so far:








As one tweet already pointed out, quoting the ACLU, "the First Amendment still protects workers' ability to speak in their own private capacities, on their own time, about matters that concern the public."

We might not be able to trust any official statements from the government for the next few years, but perhaps we'll still be able to find accurate science through the alt-gov Twitter accounts. So when you hear the Secretary of Health and Human Services (far right Congressman Tom Price, if he's confirmed) making claims about health care, check out @AltHHS to find out the real story. And when you hear Secretary of Big Oil Energy Rick Perry claim that global warming is a hoax, go to @NotAltWorld or @RogueNasa to find out the real story.

Trump's lovefest with anti-vaxxer RFK Jr.


Robert F. Kennedy Jr., liberal activist
and Donald Trump's new best friend.
Anti-vaccine conspiracy theories make for strange bedfellows. Witness this past week's widely reported meeting between Donald Trump and liberal activist Robert F. Kennedy, Jr. to discuss vaccines and vaccine policy. RFK Jr. emerged from the meeting to claim that Trump had invited him to chair a new commission on vaccines, specifically to discuss the thoroughly discredited claim that vaccines cause autism.

Talk about the blind leading the blind. Trump has been an anti-vaxxer for years (as I've pointed out before), but for him it seems more like an afterthought–yet another of the many false claims he likes to throw out at random moments. RFK Jr., in contrast, has made anti-vaccine conspiracy mongering his raison d'etre for many years, most recently when he published an entire book to promote the bogus theory that thimerosal causes autism.

Just to get this out of the way: vaccines don't cause autism. (If you want details, here's a nearly book-length article that explains more.) The thimerosal used as a preservative in vaccines was removed a decade ago (in an excess of caution), but that never caused autism either. Because of one bogus, now-retracted study published by Andrew Wakefield in 1998, millions of dollars have been spent investigating–and ultimately disproving–any possible link between vaccines and autism. All that money could have been better spent trying to find the real causes of autism, but it was wasted instead in an effort to undo the damage caused by one fraudulent doctor, Wakefield, who eventually was found to have committed fraud and lost his medical license.

Autism is a complex disease with a strong genetic component, and thousands of devoted scientists are trying to understand it better. RFK Jr. is not one of those scientists. He's a lawyer who previously devoted himself to environmental causes. He's also a ideologue who is all too willing to distort the facts and simply make things up if it suits his agenda. He and Trump share that particular style of discussion.

(Aside: it's hard to ignore the irony of a devoted liberal such as RFK Jr. joining forces with Donald Trump. For example, on the issue of global warming, in 2007 RFK Jr. said about Exxon and other companies that denied global warming, "This is treason and we need to start treating them now as traitors." Apparently he doesn't feel that way any longer.)

So back to this "vaccine commission" that RFK Jr. wants to lead. Besides the blindingly obvious fact that RFK Jr. is completely, utterly incompetent to lead such a commission, he and Trump also seem unaware that the U.S. already has a vaccine commission. It's called the Advisory Committee on Immunization Practices, and it's filled with medical experts who have spent their lives studying vaccines and vaccine safety. It also includes a consumer representative, and it is completely open, despite the conspiracy-mongering protestations of RFK Jr. If you want to see who's on it, just look here. The ACIP meets three times a year, its meeting schedule is also posted on the website, and the meetings are open to the public.

Cleary RFK Jr. loves the attention he's getting from Trump. And Trump seems to have found a soulmate in his fellow anti-vaxxer, despite RFK's strongly liberal political views. After the private meeting and RFK's announcement that Trump had invited him to chair a vaccine commission, Trump's representatives denied it. But a day later, RFK Jr. announced that he was leaving his environmental group in order to chair this hypothetical "vaccine safety" commission, and he also claimed that he and Trump had been discussing it for a month.

Putting Robert F. Kennedy Jr. in charge of a commission on vaccines is akin to putting Josef Stalin in charge of prison reform. By insisting that vaccines cause autism, both Trump and RFK Jr. have already ignored a vast body of science that shows vaccines to be not only safe, but perhaps the single greatest benefit to public health in the history of medicine. If Trump gives RFK Jr. a platform to spout his anti-vaccine nonsense, the two of them will set back healthcare by decades. Infectious diseases such as measles will return with a vengeance, and children will die. That will be an awful outcome, and no one–not even Trump or RFK Jr.–can possibly want that. Let's hope that someone in Trump's inner circle stops him before this goes any further.

Calling out fake medical journals that exist to promote acupuncture

Comic strip by Rudis Muiznecks, cectic.com
Fake news has been in the news a lot lately. Fake news proliferated wildly during the 2016 U.S. election, much of it completely fabricated, usually with an extreme partisan bias. Fake news is corrosive. It mis-informs the public, divides people against one another, leads to bad policy decisions, and can even induce people to take action against imaginary threats.

One might think that medical literature is immune from this kind of fakery, but it's not. Recent years have seen the appearance of journals from mainstream publishers that are based entirely on pseudoscience. On the surface, these publications look and act just like real scientific journals, but it's all just pretend. The publishers of these journals presumably care more about their bottom line than about scientific integrity. They know (or seem to know) that journals about pseudoscience will create a never-ending demand for fake breakthroughs and science-y sounding studies that are built on a house of cards.

I've decided to start out the new year by calling out these fake medical journals for what they are: complete and utter nonsense. First, a bit of background.

Imagine for a moment that a publisher created a Journal of Magical Medicine under the rubric of a large, respectable publisher–for example, Elsevier. After assembling an editorial board of academics from legitimate universities who believed in magical medicine, the journal started soliciting and reviewing papers. The editors would send any submissions for review to other academics who believed in magic, and over time a steady stream of peer-reviewed papers would emerge. A large network of magical medicine "experts" would develop, reviewing and citing each others' papers, and occasionally writing review articles about the state of the art in magical medicine.

Dr. Harriet Hall has accurately called this "tooth fairy science." I prefer to call it "cargo cult science," because its practitioners mimic the behavior of real scientists without actually understanding science itself.

Of course, no self-respecting scientist would want to waste his or her time reading garbage, so most scientists would simply ignore the Journal of Magical Medicine. But it would persist anyway.

This is exactly the situation we're in now, but as you might guess, the Journal of Magical Medicine doesn't exist. Instead, we have multiple journals devoted entirely to something just as fanciful and just as unbelievable: acupuncture. Here are three examples:
These aren't the only ones, but they'll do for an illustration. I can't help pointing out that the Elsevier journal has a bonus bit of magic in its name: "meridians" are a completely imaginary concept, referring to invisible lines of energy that supposedly flow through the body. This is a perfect (if unintentional) example of magical medicine. How nice that Elsevier provides a journal for people who want to study it.

Prof. Edzard Ernst has pointed out that these journals, and others like them, are a farce:
"Potential authors ... are invited to suggest their preferred reviewers who subsequently are almost invariably appointed to do the job.... As a result, most (I estimate around 80%) of the articles that currently get published on alternative medicine are useless rubbish."
If anything, Prof. Ernst is being overly generous.

Looking over the articles published in the latest issues of these journals is painful (if you care about good science, that is). For example, the BMJ acupuncture journal features "Needling depth at BL52 in 13 cadavers," an article about inserting needles into dead bodies. Why study this? Because (as the paper explains) acupuncture needles can damage the kidneys if they are inserted too deeply. Here's another example, from Elsevier's acupuncture journal: "Effect of Manual Acupuncture Stimulation at `Bai-Hui' (GV 20) or `Yintáng' (Ex-HN3) on Depressed Rats," a study that concludes that acupuncture helps alleviate depression (in rats, mind you!) but only if you use two acupuncture points simultaneously. Right.

There are thousands more articles like these. It's an entire ecosystem of pseudoscience.

Let's be clear: acupuncture is "a pre-scientific superstition" that has no basis in medicine, physiology, or biology, and has never had any good scientific evidence to support it. It wasn't even popular in China until Chairman Mao re-invented it as part of "traditional Chinese medicine." Mao did this because China didn't have enough real doctors to treat its large population, and he wanted to convince the masses that their local herbalist was offering something just as good. China is still pushing this today, for the same unscientific reasons.

I've been advised that I should treat acupuncturists and acupuncture believers with respect, and that I should accept that they have some legitimate claims because some patients like them. I've tried this approach, and it doesn't work: acupuncture continues to spread, in part because of very badly-done studies that often misrepresent their findings. I've read enough acupuncture studies for one lifetime, and acupuncture doesn't work for anything. It's nothing more than an elaborate, theatrical placebo, performed by quacks to convince unwitting victims patients that the acupuncturists have something real to offer. They don't.

Trying to refute the claims of acupuncture (see here and here, and again here, for example) is like playing whack-a-mole. Proponents claim it cures dozens (or hundreds) of different conditions, and each time a claim falls flat, they simply make up a new one. Acupuncture also carries small but real risks to patients, who can suffer infections and sometimes much worse, such as punctured lungs.

Elsevier, BMJ, and Biomed Central should be embarrassed to publish these fake medical journals, which serve only to promote pseudoscience. Their very existence can confuse medical students, who assume (as they've told me themselves) that if legitimate-looking journals are publishing this stuff, there must be something to it.

Despite their appearances, the Journal of Acupuncture and Meridian Studies, Acupuncture in Medicineand Chinese Medicine are not real medical journals. They are fake journals filled with fake science, and the world would be a better place if they all disappeared.