$545 million wasn't enough for chiropractors. Now they're lobbying Congress for much more.

Medicare currently wastes more than $545 million a year on chiropractors, as I revealed in an article last year. Wasteful as this is, it's not enough for chiropractors, who have successfully lobbied to have two Congressmen propose a new bill, HR3654, that will require Medicare to pay chiropractors for the full range of services that real doctors offer.

The American Chiropractic Association is practically rubbing its (metaphorical) hands together with glee. As they proudly point out, this endorsement of quackery is bipartisan: the bill is sponsored by two New York Congressman, Democrat Brian Higgins and Republican Tom Reed.

The idea of having chiropractors function as regular physicians is very troubling. Chiropractors do not receive proper medical training: they get their Doctor of Chiropractic (D.C.) degrees from one of a very small number of special chiropractic schools, which do not provide the full medical training that real medical schools do. Their curriculum also includes a heavy dose of pseudoscience, especially the training around subluxations.

For a detailed discussion of why chiropractors are not competent to be family physicians, I recommend this article by an experienced physician, Dr. Harriett Hall, titled "Chiropractors as family doctors? No way!" Dr. Hall goes into considerable detail explain why many of the medical practices of chiropractors are non-standard, not evidence-based, and possibly harmful. Or see this lengthy takedown of chiropractic subluxations by Sam Homola, a former chiropractor.

Many chiropractors are also anti-vaccine, unfortunately, as documented just two weeks ago in this article by attorney Jann Bellamy. Among other things, Bellamy points out that a major chiropractic conference this fall will feature a keynote talk by anti-vaccine activist Robert Kennedy Jr. (about whom I've written before).

Even more alarming, as I've explained before, is that chiropractic neck manipulation has been shown to carry a small but real risk of stroke, because it can create a tear in your vertebral arteries. For example, this report from 2016 documented a case of cerebral hemorrhage apparently caused by chiropractic manipulation. The patient in that case was a 75-year-old woman, which puts her squarely in the class of patients eligible for Medicare.

And to those chiropractors who've read this far: I'm sorry that you were hoodwinked into spending 3-4 years in a chiropractic school, paying nearly $200,000 in tuition and fees, with the promise that you'd be a legitimate medical professional. You were scammed, and I'm sorry about that. And I understand that most (perhaps all) chiropractors want to help their patients. The problem is, the training offered by chiropractic colleges is far short of a proper medical degree.

If the chiropractors' lobbying association get its way, this $545 million (annually) in wasted Medicare dollars will soon become a far higher amount–to the detriment of patients. The bill will allow chiropractors to bill Medicare for pretty much any service that a bona fide physician offers.

It's also worth noting that in 2018, Medicare's Inspector General issued a report titled "Medicare needs better controls to prevent waste, fraud, and abuse related to chiropractic services," which revealed that almost half of Medicare spending on chiropractic care from 2010-2015, between $257 million and $304 million per year, was likely wasted or fraudulent. One wouldn't think this is a time to expand Medicare's coverage of chiropractic.

Congress, don't be fooled by arguments that this proposed new law will lower medical costs, or give patients what they need: it won't. Instead, it will dramatically increase the amount of funds wasted on ineffective treatments. The U.S. does need a better health care system, but this bill would be a big step in the wrong direction.

Hey, NY Times: Keep your hands off my smoked salmon

For lovers of smoked salmon, the New York Times featured an alarming headline last week: "Do Lox and Other Smoked Fish Increase Cancer Risk?" The article reported that the American Institute for Cancer Research, a respected nonprofit organization, considers smoked fish (including lox) to be in the same category as "processed meat." The Times answers its own question with "it might."

The Times is wrong. If anything, smoked salmon is good for you. Let me explain.

Where does the concern come from? In 2015, a major report from the International Agency for Research on Cancer (IARC) concluded that red meat and processed meat probably cause cancer, especially colon cancer. To be precise, they wrote that
"there is sufficient evidence in human beings for the carcinogenicity of the consumption of processed meat."
And what, you might ask, is processed meat? According to the IARC:
"Processed meat refers to meat that has been transformed through salting, curing, fermentation, smoking, or other processes to enhance flavour or improve preservation."
Although the 2015 IARC report didn't mention smoked fish, the NY Times reporter, Sophie Egan, points out that smoked salmon (lox) is also transformed through salting and smoking (or curing, if you consider gravlox). To support this concern, Egan quotes Alice Bender, a dietitian (with a master's degree but not a doctorate) from the American Institute for Cancer Research. According to Bender, who was not involved in the IARC report,
"Even though it’s possible that processed fish and even chicken and turkey could be better alternatives [to processed meats], for now we have to look at all of it as processed meat."
No, we don't.

I read the IARC report, and it doesn't mentioned smoked fish. It states that processed meats usually "contain pork or beef, but might also contain other red meats, poultry, offal (eg, liver), or meat byproducts such as blood." And an earlier report gave these examples of processed meats: ham, bacon, sausages, blood sausages, meat cuts, liver paté, salami, bologna, tinned meat, luncheon meat, and corned beef. Nothing about fish.

However, I wanted to be certain, so I dug down into the original research. The IARC report is based on a whole raft of earlier studies, which they combined and summarized, and it turns out that some of those studies did indeed look at smoked fish.

In particular, this IARC study from 2007–one of the studies that the 2015 IARC report relied upon–looked at both meat and fish and how they affected the risk of colon cancer. The 2007 study found that consumption of fish reduced the risk of cancer. And most important for today's discussion, they stated explicitly that
"Fish included fresh, canned, salted, and smoked fish."
There you have it. Consumption of fish, including smoked fish, reduces the risk of colon cancer. (A minor caveat: smoked salmon does have a high level of salt, which can be a concern for people with high blood pressure.)

So my response to the NY Times: keep your hands off my bagels and lox. Really, you should know better.

The US will try treating opioid addiction with fake medicine

If you can't afford to offer real medical care, why not offer fake medicine? The U.S. Medicare system is about to give this strategy a try, for treating back pain.

Last week, Medicare announced that it wants to start paying for studies of acupuncture as a treatment for low back pain, as reported by the Washington Post and Stat. The government's reason, according to Secretary of Health and Human Services Alex Azar, was that we need this option to help solve opioid addiction:
“Defeating our country’s epidemic of opioid addiction requires identifying all possible ways to treat the very real problem of chronic pain, and this proposal would provide patients with new options while expanding our scientific understanding of alternative approaches to pain.”
If you break down HHS Secretary Azar's statement, it's mostly correct. Yes, treating opioid addition should explore all methods for treating chronic pain. And yes, this program will provide "new" options, even though the option in question is nonsense.

But (3) no, studying acupuncture will not expand our scientific understanding of "alternative approaches" to pain. Why not? Because thousands of studies have already been done, and the verdict was in, long ago, that acupuncture is nothing more than an elaborate placebo.

The problem is, acupuncture proponents never give up. Every time a study shows that acupuncture fails (and this has happened, repeatedly), they claim it wasn't done properly or make another excuse. I've even seen proponents argue that studies in which acupuncture failed were in fact successes, because acupuncture and placebo treatments both outperformed the "no treatment" option.

(Aside: we use placebo treatments because we've known for decades that any treatment, even a sugar pill, may show a benefit as compared to no treatment at all. Acupuncture research has created placebos by using fake needles that don't actually pierce the skin, or by placing needles in random places rather than the so-called acupuncture points. Scientifically speaking, if a treatment doesn't outperform a placebo, then the treatment is a failure.)

To make matters worse, the new HHS program will fund "pragmatic" clinical trials rather than the usual, gold-standard randomized trials (RCTs). Without going into details, let's just say that pragmatic trials are much less well-controlled than RCTs, allowing more room for mistakes and misinterpretation. This is a bad idea even when the intervention being studied is legitimate. It's an even worse idea here, where trials have shown, over and over, that acupuncture doesn't work.

Secretary Azar might be confused because the acupuncture industry has managed to get hundreds of studies published, many of them positive–but most of them are poorly designed, and who has time to read all that bad science? (The rare well-designed studies always show that acupuncture doesn't work.) Acupuncturists have even created pseudoscientific journals devoted entirely to acupuncture, as I wrote about in 2017. Some of these journals are published by respected scientific publishers, but they are still little more than fake journals.

Not surprisingly, with entire journals trying to fill each issue with acupuncture articles, last week's Medicare announcement noted that
"the agency [CMS] recognizes that the evidence base for acupuncture has grown in recent years". 
No, it hasn't. What has grown is the number of articles. Adding more garbage to a pile doesn't make it smell better.

For those who aren't familiar with the claims of acupuncture, let's do a very quick summary: acupuncturists stick needles in a person's body at specific points in order to manipulate a mystical life force that they call "qi" (proounced "chee"). This idea 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.  Acupuncturists don't even agree on where the acupuncture points are, which should make it impossible to do a scientific study. It's not at all surprising that acupuncture doesn't work; indeed, if it did work, modern medicine would have to seriously examine what mechanism could possibly explain it.

But wait, argue proponents, what about all the wise traditional doctors in China who developed acupuncture over thousands of years? Well, it turns out that acupuncture wasn't popular in China until the mid-20th century, when Chairman Mao pulled a fast one on his population because he couldn't supply enough real medical care. Mao didn't use acupuncture himself and apparently didn't believe in it. I highly recommend this expose of Mao's scam, by Alan Levinovitz in Slate.

So rather than spend millions of dollars on yet another study of acupuncture for pain, I have a better suggestion for HHS: invest the funds in basic biomedical research, which has had a flat budget for more than a decade now. As long as it goes through proper peer review, almost any research will be far better than wasting the money on acupuncture.

Now, I'm not naive enough to think that Medicare will take my advice, but I can tell them right now what their new "pragmatic" trials will reveal. Acupuncturists will happily take the money, treat people suffering from back pain, and report that some of them experienced reductions in pain. Some of the patients will invariably agree, because back pain comes and goes, and it's hard to know why it went away.

Then the acupuncturists will say, "look, it works! Now please cover acupuncture for all Medicare patients." Then we'll spend more tax dollars on pseudoscience, and patients will be in just as much pain as ever. If Medicare falls for this (and I fear they will), then Chairman Mao will have fooled the U.S. government, just as he fooled many of his own people half a century ago.

The loneliest word, and the extinction crisis

We're in the midst of an extinction crisis. Just two months ago, an international committee known as IPBES released a report, compiled over 3 years by 145 experts from 50 countries, that said 1,000,000 plant and animal species are threatened with extinction, many within the next few decades.

Martha, the very last passenger
pigeon, shown when she was
still alive.
Before getting to that report, I want to introduce a word that I only just learned: endling. An endling (the word was coined in 1996) is the last surviving member of a species. One example was Martha, the very last passenger pigeon, who died in the Cinncinnati Zoo in 1914. Passenger pigeons numbered in the billions in the 19th century, but humans wiped them out.

In 2012 we lost another endling, Lonesome George–the very last Pinto Island tortoise from the Galapagos Islands–who died at around age 100.

If you want to see a particularly poignant example of an endling, watch this rare and heartbreaking video of Benjamin, the very last Tasmanian tiger (or thylacine), pacing around his cramped enclosure in Hobart, Tasmania. This film from 1933 is the last known motion picture of a living thylacine. Benjamin died in 1936.
Two Tasmanian tigers in the Washington, D.C. zoo, in a photo
taken around 1904. Photo credit: Baker; E.J. Keller. from the
Smithsonian Institution archives

We have records of other endlings too: the last Caspian tiger was killed in the 1950s in Uzbekistan, and the last great auks were killed for specimen collectors in 1844.

Unfortunately, we're likely to see more and more endlings in the years to come. The causes of extinction are varied, and many of them are related to human activities. The IPBES ranked the culprits, in descending order, as:

  1. changes in land and sea use,
  2. direct exploitation of organisms,
  3. climate change,
  4. pollution, and
  5. invasive alien species.

In response to the IPBES report, the House of Representatives held a hearing in May to discuss the findings. Republicans on the committee took the opportunity to display a new form of denialism: extinction denialism. As reported in The Guardian, Representatives Tom McClintock and Rob Bishop used their time to attack the reputations of the report's authors, rather than addressing the very serious consequences of large-scale extinction. They called two climate-change deniers as witnesses, who also used their time to attack the authors.

This is a classic strategy used by deniers: attack the messenger, rather than dealing with the substance of the report. Let's consider just a few of the report's main findings (see much more here):

  • Across the planet, 75% of the land and about 66% of the marine environments have been significantly altered by human actions.
  • Up to $577 billion in annual global crops are at risk from pollinator loss (bees and other insects)
  • In 2015, 33% of marine fish stocks were being harvested at unsustainable levels; 60% were maximally sustainably fished.
  • Plastic pollution has increased tenfold since 1980, 300-400 million tons of heavy metals, solvents, toxic sludge and other wastes from industrial facilities are dumped annually into the world’s waters, and fertilizers entering coastal ecosystems have produced more than 400 ocean ‘dead zones’, covering a combined area greater than that of the United Kingdom.

The report is a call to action. It explains that transformative change is needed to protect and restore nature, and collective action is needed to overcome special interests such as the fossil fuel industry, which donates heavily to politicians. The Congressional hearing was a vivid demonstration of how effective the anti-environmental lobbyists have been.

Endling is the saddest word in any language. If we humans continue to treat nature as we've done in the past, we're going to see many more videos like the one of Benjamin, the last Tasmanian tiger. Let's hope we can do better.

Does the length of your fingers predict sexual orientation?

Imagine my surprise last week when I saw an article in Science that claimed "finger lengths can predict personality and health."* Huh?

The author, science writer Mitch Leslie, gives us the rather startling number that over the past 20 years, more than 1400 papers have been published linking finger lengths to personality, sexual orientation, cardiovascular disease, cancer, and more.

What is this magical finger length ratio? Simple: it's the ratio between the lengths of your index (2nd) and ring (4th) fingers, also called the 2D:4D ratio. Take a look: is your index finger longer than your ring finger?

It turns out that most people have slightly longer ring fingers than index fingers, and in men the difference is a bit larger. If the ringer finger is longer, than the 2D:4D ratio is less than one. One recent study reported that this ratio was 0.947 in men and 0.965 in women. Another study found average values of 0.984 and 0.994 for men and women. Not only is this a tiny difference, but in every study, the 2D:4D ratio among men and women overlapped, meaning the number alone doesn't tell you very much.

Nonetheless, some researchers have taken this tiny physiological difference and run with it. Nearly 20 years ago, Berkeley psychologist Marc Breedlove (now at Michigan State) published a study in Nature where he and his colleagues measured finger-length ratios in 720 adults in San Francisco. Based on this data, they concluded that finger-length ratios show
"evidence that homosexual women are exposed to more prenatal androgen than heterosexual women are; also, men with more than one older brother, who are more likely than first-born males to be homosexual in adulthood, are exposed to more prenatal androgen than eldest sons."
Whoa! They are not only claiming that the 2D:4D ratio is predictive of homosexuality, but also that exposure to prenatal androgen is the root cause of both finger lengths and sexual orientation. (Confusing correlation with causation, perhaps?) Not surprisingly, this claim is not widely accepted.

There are many, many more claims out there. In 2010, the BBC boldly reported that 
“The length of a man's fingers can provide clues to his risk of prostate cancer, according to new research.”
based on this study in the British Journal of Cancer. That study found that men whose index fingers were longer than their ring fingers had a reduced risk of cancer. (I don't believe it for a second, but if it makes you feel better, go ahead.) And a 2016 report found that both men and women with a low 2D:4D ratio (longer ring fingers) had better athletic abilities. 

The Science article goes on to explain, though, that "the results often can't be replicated." Most of these studies are small, the measurement techniques vary widely, and efforts to reproduce them (when others have tried, which isn't that often) usually fail. It didn't take me long to find a few, such as this study from 2012, which swas the 2nd failure to replicate a result claiming a link between sex hormone exposure and the 2D:4D ratio.
The author's left hand

After reading the whole Science article, one comes away with the impression that finger ratio science is almost certainly bogus. The presentation, though, gives far more space to the claims of those who believe in it, and one gets the strong impression that the journalist (Mitch Leslie) is on their side. A hint to that is in his last sentence where, after saying that the two sides are "talking past one another," he writes "more than 20 papers using the digit ratio have already come out last year."

And since the last sentence is often a giveaway for what the writer really thinks, let me conclude by saying that both my ring fingers are longer than my index fingers.

[*The print version of Science contains precisely this claim in the subheading to the article: "Some researchers say a simple ratio of finger lengths can predict personality and health." Interestingly, the online version of the same article does not have this headline. Instead, it reads "Scientists try to debunk idea that finger length can reveal personality and health." It appears as if the online editors were more skeptical than the print editors.]

Google ran a secret experiment to search for cold fusion. Did they find it?

A non-working cold fusion apparatus
at the San Diego Naval Warfare 
Center. Source: Wikipedia
The journal Nature last week revealed the results of a 4-year, $10 million experiment to test cold fusion. The experiments were kept secret in order to avoid the negative publicity that cold fusion attracted when it burst upon the scene 30 years ago.

I've been talking to a few non-scientists about this, and it appears that many people don't know about the cold fusion saga, so here's a quick recap: back in 1989, two chemists at the University of Utah, Stanley Pons and Martin Fleischmann, held a press conference to announce a startling discovery: they had generated fusion energy at room temperature. If true, this would have been a profound, civilization-changing discovery: cold fusion had the potential to provide nearly free energy to the entire world, eliminating our dependence on fossil fuels and promising unheard-of economic and environmental benefits.

[A physics aside for those who might be curious: fusion energy is produced when two atoms are smashed together to form a new, heavier atom. Four hydrogen atoms can be fused to form one helium atom, for example. A tiny bit of mass is converted to energy in the process, and that tiny amount produces enormous amounts of energy, as given by Einstein's famous equation, E=MC2. Fusion is the process that powers the sun and other stars, but humans have never been able to control it. It's also the source of the energy released by a thermonuclear bomb. The only nuclear energy we humans can control is fission, which is what nuclear power plants use. And the only fusion we know about requires crazily high temperatures, which is why room temperature would be "cold."]

Unfortunately for Pons and Fleischmann, whose reputations were forever tarnished, the 1989 experiments were fatally flawed. Many scientists tried to reproduce the results, but they all failed, and the criticism mounted quickly. Pons and Fleischmann never published their findings, and cold fusion later became a meme for flawed or impossible scientific results. Even today, calling something "cold fusion" is form of ridicule.

Despite the dramatic failure 30 years ago, cold fusion isn't fundamentally impossible, unlike homeopathy, acupuncture, reiki, or other forms of pseudoscience. Fusion is a very real phenomenon, and no one really knows if it might be possible to sustain a fusion reaction at low temperatures, or what those temperature limits might be. This is what led Google and the scientific team they funded to give cold fusion another serious look.

The new Google-funded experiments were run by a team of about 30 graduate students, postdoctoral fellows, and professors. The seven leaders of the team, who include scientists from UBC, MIT, the University of Maryland, LBL, and Google, described their findings in a paper just published in Nature. After four years of careful experiments, they conclude:
"So far, we have found no evidence of anomalous effects claimed by proponents of cold fusion."
In other words, they couldn't get cold fusion to work. They tried 3 different experimental setups that have been proposed by others, but despite their best efforts, nothing produced any signs of fusion energy.

The news isn't all negative. The scientists emphasized that in the course of trying to produce cold fusion, they had to design new instrumentation and study new types of materials that have received little attention before now. They wrote:
"... evaluating cold fusion led our programme to study materials and phenomena that we otherwise might not have considered. We set out looking for cold fusion, and instead benefited contemporary research topics in unexpected ways."
They cite go on to say:
"Finding breakthroughs requires risk taking, and we contend that revisiting cold fusion is a risk worth taking."
I have to agree with them here. As the scientists themselves pointed out, even though their experiments didn't produce cold fusion, "this exploration of matter far from equilibrium is likely to have a substantial impact on future energy technologies." In other words, if we keep trying, who knows what we might find?


Does ginkgo biloba enhance memory? I forgot.

I recently saw an ad that claimed ginkgo biloba can treat the signs of dementia. A quick search on Amazon.com yielded hundreds of products, many claiming that gingko is a "brain sharpener" or that it "supports focus, memory, brain function and mental performance," or other similar claims.

Ginkgo biloba is a supplement made from the leaves of the gingko biloba tree, which is native to China. The supplements industry claims that gingko has been used for thousands of years to improve memory and stave off dementia. While that may be true (though I doubt it), the argument that a medical treatment was used by pre-scientific cultures is not exactly compelling. After all, people died very young in ancient times, and medical knowledge was little more than superstition, for the most part. I don't know about you, but when I'm looking for medicine, I want the latest stuff.

"But wait!" say ginkgo biloba's advocates: maybe those ancient folk doctors were onto something. Maybe so–and it didn't take me long to find multiple studies testing what those ancients supposedly believed about gingko biloba:

  1. Here's a review from 2009 that looked at gingko biloba for dementia and milder cognitive impairment. It reported that "the evidence that Ginkgo biloba has clinically significant benefit for people with dementia or cognitive impairment is inconsistent and unreliable." Not exactly a ringing endorsement.
  2. Here's another study, from 2012, looking at the effect of gingko biloba on memory in healthy individuals. Is it a "brain sharpener"? Well, no. This study found that gingko "had no ascertainable positive effects on a range of targeted cognitive functions in healthy individuals." In other words, a total dud.
  3. And here's an even more recent study, from 2015. The result: "no convincing evidence ... that demonstrated Ginkgo biloba in late-life can prevent the development of dementia. Using it for this indication is not suggested."

Given that the science says this doesn't work, you might wonder how it is that hundreds of gingko biloba products are still on the market, all of them with claims about memory. Simple: it's a dietary supplement, not a drug, which means that it is essentially unregulated (in the U.S.). The FDA won't step in unless the marketing claims get so outrageous that they cross the line into medicine–and even then, the FDA rarely does more than send a sternly worded letter.

As I've written before, supplement marketing is like the wild west. You generally can't trust anything you read from the manufacturers, except perhaps the ingredients list. And even the ingredients are sometimes inaccurate and contaminated.

(By the way, I find it especially amusing when a pill that has no effect is advertised as "double strength," as Walgreens does for one of their gingko products, here.)

So be skeptical about the marketing claims for gingko biloba. Even NCCIH, the NIH institute whose mission is to promote "alternative" medicine, is remarkably clear about this, stating that:

  • "There’s no conclusive evidence that ginkgo is helpful for any health condition.
  • Ginkgo doesn’t help prevent or slow dementia or cognitive decline.
  • There’s no strong evidence that ginkgo helps with memory enhancement in healthy people, blood pressure, intermittent claudication, tinnitus, age-related macular degeneration, the risk of having a heart attack or stroke, or with other conditions."

I must say, I'm feeling a bit better about NCCIH these days. They got this one right. The bottom line: don't waste your money on gingko biloba.