Would you trust your kids with this man? No? I didn't think so.

Today I want to shine a bit of light on the conspiracy theorist behind the film "Vaxxed" and its recent sequel, "Vaxxed II." I'm not going to provide any links to the movie, or to describe it, except to say that it's a slickly-produced conspiracy theory masquerading as a documentary. Don't watch it.

Anti-vax activists often use conspiracy theory tactics, which work like this: they simply make up a claim, out of thin air, that a secret cabal of doctors (or government scientists, or pharma companies) is out to harm patients by giving them vaccines, and is hiding the "truth" about the risks of vaccination. Never mind how irrational this is, and never mind that there's not a shred of evidence behind it: if you try to argue with the anti-vaxxer, you're part of the conspiracy.

So rather than try to disprove something that was never proven in the first place, let's look instead at the source of the anti-vax propaganda film, "Vaxxed." The source is one man: Andrew Wakefield. Who is this guy, and why is he so obsessed with vaccines?

Wakefield was once a doctor, before he had his license revoked a decade ago. In his former life, he was a gastroenterologist, with no special training in vaccines or infectious diseases. He first gained fame–a lot of fame–for a 1998 paper in a medical journal, The Lancet, in which he claimed to have discovered a link between the MMR vaccine (that's the one that covers measles, mumps, and rubella) and autism.

Here are some things you need to know about Wakefield before watching his movie:

  1. Wakefield's 1998 paper, it eventually turned out, was "an elaborate fraud." Wakefield defrauded the public, his patients, and even his own co-authors on the paper, most of whom were unaware of his elaborate conflicts of interests.
  2. Before he published his 1998 study, Wakefield was hired by a lawyer, Richard Barr, who was trying to build a lawsuit against vaccine makers. Barr paid Wakefield £435,000 (equal to $750,000 US dollars at the time) to help him build his case. Wakefield's co-authors were unaware of this contract.
  3. The study claimed that 8 out of 12 children had been diagnosed with autism soon after getting the MMR vaccine. It described these children as "a consecutive series" of admissions to the hospital where Wakefield worked. That was a lie. It turned out, as investigative journalist Brian Deer revealed, that all 12 children and their parents were referred to Wakefield by Barr–the lawyer who was paying Wakefield to conduct the study, and who was trying to sue vaccine makers.
  4. Wakefield also falsified data on all 12 of the children in his original study.
  5. Wakefield conducted "invasive and distressing procedures" on the children without approval from his hospital's ethics board.
  6. After learning some of the back story, 10 of his 12 co-authors tried to retract the paper in 2004. Wakefield refused to join them, so they published a partial retraction, signed by the 10 co-authors. The Lancet itself later fully retracted the paper (over Wakefield's objections), but it took until 2010 for them to act. By then, the anti-vax movement had spread widely.
  7. Prior to publishing his paper, Wakefield filed a patent claim for a "safer" vaccine for measles, one that would have profited him greatly once he discredited the (perfectly safe) MMR vaccine.
  8. After losing his license in the UK, Wakefield moved to Austin, Texas where he ran an organization called Thoughtful House, through which he paid himself a salary of $280,000. (Perhaps coincidentally, Austin is now a hotbed of anti-vaccination activism.)

For more than 20 years, Andrew Wakefield has made money off false claims that vaccines cause autism, first put forth in his discredited 1998 paper. He gives talks, writes books, conducts seminars, and now makes movies, of which make him money. Since the publication of his paper, dozens of studies involving literally millions of children have shown, time and again, that vaccines do not cause autism. Wakefield has denied every one of those studies, and continues to push his bogus claims.

(Why, you might ask, have scientists conducted studies looking for a link between autism and vaccines, if there was never any evidence for such a link? The answer is simple: anti-vaxxers have been so successful at scaring people about a nonexistent threat that scientists and public health experts felt it necessary to conduct those studies, in order to reassure people. Literally millions of dollars have been spent to prove something we already knew.)

Meanwhile, measles outbreaks have appeared with increasing frequency in the U.S., the UK, other European countries, and around the world, including the deadly outbreak in Samoa late last year, which caused 5,700 infections and 83 deaths in a population of just 200,000. Wakefield's new movie was released in the middle of that outbreak.

So to anyone who watched the movie Vaxxed and is now having doubts about vaccines, I ask: would you trust your children with this man? I wouldn't.

Are you "vaccine hesitant"? You may be in a cult

Edward Jenner, who pioneered vaccination, and two colleagues
 (right) seeing off three anti-vaccination opponents, with the dead
lying at their feet (1808). 
I Cruikshank/Wellcome Images/Wikimedia
The World Health Organization recently declared that "vaccine hesitancy," as they called it, was one of the top 10 threats to global health. That's right: it was up there with air pollution, climate change, influenza, Ebola, and other threats.

For the WHO, "vaccine hesitancy" is a polite phrase designed to engage the public and highlight how serious the problem is, without angering those who are guilty of it. I'm not going to be quite so polite here: "vaccine hesitant" means anti-vax. The anti-vax movement, which aggressively spreads fear and misinformation about vaccines, has become a major, worldwide threat.

It also resembles a cult, as I'll explain.

The most recent anti-vax nonsense centers on the new coronavirus that originated in China, and that has led the Chinese government to impose a massive quarantine affecting millions of people. This is a genuine public health crisis, and it has nothing to do with vaccines. Nonetheless, some anti-vaxxers are claiming, without evidence, that the new virus originated from a failed effort to create a coronavirus vaccine. I don't have time to get into that here, but Orac has a lengthy, detailed takedown of that bogus claim.

"Vaccine hesitancy" sometimes refers to parents who are just learning about vaccines for the first time, and who rely on the Internet to search for information. Unfortunately, these new parents are likely to be flooded with anti-vax messages, especially on Facebook. (In recent years, Google has taken steps to lower the priority of anti-vax sites, which has improved things considerably. Sites such as healthychildren.org now appear near the top of searches for "vaccine safety.") It's entirely reasonable to ask your doctor about the benefits and risks of vaccines.

But the answers that parents hear should be clear: vaccines work. As physician ZDoggMD (a pseudonym, obviously) explains in this video:

"Anti-vaccine sentiment is a poisonous scourge.... There's no debate about vaccines. Let's get over that nonsense that the media and celebrities have created, okay? There is nobody in the medical community of any actual reputation who believes that there are two sides to this."
The problem is that anti-vaxxers are continuously creating new websites, Facebook groups, and even movies to spread misinformation about vaccines, particularly the long-debunked claim that vaccines cause autism.

Why do I suggest that anti-vaxxers resemble a cult? Because they have several of the key features of cults, such as:

  1. Members of the cult have special insights that outsiders cannot comprehend. With anti-vaxxers, this means they are completely convinced that they know that vaccines cause harm, despite mountains of evidence to the contrary.
  2. The group and its leaders are the exclusive means of knowing "truth" or receiving validation, and no other process of discovery is credible. The anti-vax movement has had several prominent leaders, whose followers flock to their speeches and events. These include Andrew Wakefield, the disgraced former doctor who lost his medical license after it was revealed that he had committed fraud. His followers, though, either don't know or ignore his fraudulent past, and regard him as a hero. He makes a living from his books, a movie, and speaking fees, all based on spreading fear about vaccines. An even more prominent anti-vax leader is Robert Kennedy, Jr., who also sells books and gives speeches proclaiming the harms of vaccines. Thanks to his famous name, and despite the fact that he has no medical or scientific training, some people believe him.
  3. Unreasonable fear about the outside world, such as impending catastrophe, evil conspiracies and persecutions. Conspiracy theories are the core of many anti-vax arguments. The most common version holds that the "medical establishment" (whoever that is) are hiding the dangers of vaccines so that they can make money. This is utter nonsense. All of doctors I know in the infectious disease community are motivated by a wish to cure disease. In any case, most doctors make little or no money from the vaccines they administer.
  4. No meaningful financial disclosure regarding budget or expenses. Some anti-vaxxers profit handsomely by selling bogus, ineffective supplements as alternatives to vaccines. (I'm looking at you, Joe Mercola.) Because supplements are largely unregulated, they get away with it. They'd prefer you to think they're "just in it for the children."

I've no doubt that anti-vaxxers like Wakefield, Kennedy, and others would deny that they are conspiracy theorists, because that's how conspiracy theorists operate. If you question them (they argue), you must be part of the conspiracy. By their own reasoning, they can never be wrong.

So if you encounter someone, either on the sidelines at your kid's soccer game, on Facebook, or elsewhere, who is spreading claims that vaccines are harmful, pause for a minute and ask: what is the source of this information? Is it coming from someone who is profiting from this fear-mongering? There's a good chance the answer is yes.

It's ironic that when the world is faced with a true health emergency, such as the Ebola virus or the Wuhan coronavirus, the first thing that public health experts start to work on is a new vaccine. That's because vaccines provide our best protection against infections. We now have effective vaccines for 16 diseases that used to harm and even kill children in large numbers around the world. We've eliminated smallpox worldwide, and we've nearly eliminated polio, thanks to vaccines. Their very effectiveness is what has allowed the anti-vax message to take hold: many people are no longer frightened of dying from infectious diseases.

We're still a long way from conquering infections, but there's no reason for the world to slip back in time to an era when large numbers of people died from preventable infections. Vaccines work, if we'll let them.

Surprise! Many organic foods are GMOs, and they are transgenic

A new study finds that many common foods, including beer and tea, turn out to be "natural" GMOs. What's a health-food purist to do?

Even though no one has found any evidence that genetically modified organisms (GMOs) are harmful, anti-GMO activists have campaigned against them for years, with considerable success. As of this writing, 19 out of 28 countries in the European Union have voted to ban or severely restrict genetically modified plants, and many other countries impose similar bans.

But all of these restrictions may be in vain, because nature got there first. It turns out that many common foods have already been genetically modified, by a bacterium called Agrobacterium. (Read on to see the list.) And, in news that should be even more frightening to the anti-GMO crowd, these foods are transgenic: they contain genetic material from completely different species. Frankenfoods!

First, as I've argued before, genetic modification technology is just a tool, and a very precise one at that. Scientifically, claiming that GMOs are bad for you is nonsensical–it depends entirely on what the genetic modification is. Whether a food scientist modifies a tomato to taste better by traditional breeding or by using GM technology, you still end up with a tomato that has different genetic content. The only difference is that with traditional breeding, you have no idea what exactly you changed in the plant's DNA. And humans have already consumed billions of servings of GM foods with no ill effects. The GM foods we eat today are perfectly safe.

So back to my first point. What are all these natural Frankenfoods, and how did they get that way?

I'll start with the common sweet potato, or yam. Humans eat hundreds of varieties of sweet potatoes, and you can buy them in markets on every continent. Back in 2015, a group of scientists from Belgium, Peru, China, and the US (Tina Kyndt and colleagues) discovered that every cultivated variety of sweet potato has "foreign" DNA integrated into its genome, from a bacterium called (appropriately) Agrobacterium. They tested 291 different varieties, and found the bacterium 100% of the time. They also tested wild relatives of sweet potato, and found that the wild varieties (which humans don't eat) are missing the bacterial DNA.

Agrobacterium is a bacterium with special properties: it has evolved to be able to insert its DNA directly into the genomes of a wide variety of plants. (Don't worry, it doesn't infect humans.) In sweet potatoes, this happened naturally, centuries or millenia ago, long before humans were cultivating it. But then we came along, and (apparently) we liked the taste of these naturally transgenic sweet potatoes, so those are the ones that we chose to cultivate. As a result, all the sweet potatoes we eat are GMOs, although it happened naturally.

That was five years ago. But in a newly published study, scientists Tatiana Matveeva from Russia and Léon Otten from France discovered that Agrobacterium has made its way into dozens of other plants, including some of our favorite foods and drinks. Matveeva and Otten searched through the genomes (the DNA) of hundreds of plants, and found 39 natural GMOs, as they called them.

So without further ado, here are the natural GMO foods, all of them transgenic, with the common name followed by the formal species name in italics:

  • bananas (Musa acuminata)
  • beer (hops) (Humulus lupulus)
  • cranberries (Vaccinium macrocarpon)
  • date-plum (Diospyros lotus)
  • guava (Psidium guajava)
  • peanuts (Arachis hypogaea)
  • pomelo fruit (Citrus maxima)
  • Suriname cherry (Eugenia uniflora)
  • sweet potatoes (Ipomoea species)
  • tea (Camellia sinensis, which is used for most teas)
  • walnuts (Juglans species)
  • yams (Dioscorea alata)

That's right, beer and tea are GMOs–even if they are labelled as "organic." Keep in mind that this list is undoubtedly incomplete: the new study relied on current genome databases, which are still missing many common foods. 

If you're reading this, you've probably already consumed countless servings of transgenic, GMO foods. As I wrote above, there's no reason to believe that GMO foods are harmful in any way. Plenty of plants are naturally poisonous, of course (think hemlock), but widely-consumed foods got that way for a reason: people like to eat them, and they help sustain us.

If you believe the alarmist claims of the anti-GMO movement, then you're going to have to start avoiding many more foods, including everything on the list above. And yes, that includes beer. 

A new kind of fasting provides significant immune system benefits

I've written about fasting and its effects on health before. Six years ago, a study showed that a 3-day fast can essentially reset the immune system, providing many potential benefits. These benefits include better cardiovascular health, better endurance, lower blood pressure, and reduced inflammation.

Newer data, which I'll get to in a minute, shows that you might not have to fast nearly that long to get these benefits.

In the 2014 study, Valter Longo and colleagues at USC found that fasting lowered white blood cell counts, which in turn triggered the immune system to start producing new white blood cells. White blood cells (or lymphocytes) are a key component of your body’s immune system. Once you start eating again, according to Longo, your stem cells kick back into high gear to replenish the cells that were recycled.

The idea behind this strategy is that you have to fast for several days to get the benefits: basically, you have to fully deplete your energy reserves (in the form of glycogen), and it takes your body at least 24 hours, and probably 48 hours or more, to do this. That's the not-so-good news. The good news is that you probably only need to fast once or twice a year to gain the benefits that Longo described.

Last week, in a paper just published in the New England Journal of Medicine, Rafael de Cabo and Mark Mattson reviewed multiple strategies for fasting that have been tested in the years since Longo's study. The news continues to be very encouraging: intermittent fasting is good for you. I don't have time or space here to discuss all the results, but I want to focus on one fasting strategy that has surprisingly good benefits.

It turns out that you can get many of the benefits of fasting without doing a 3-day fast, which for most people is really, really difficult to accomplish. Instead, you can try a much easier type of fasting, called "time-restricted" fasting. With this strategy, you fast every day, by eating all of your food in a 6-hour or 8-hour window. Or you can go with the more difficult strategy (but still easier than a 3-day fast) where you fast for 2 entire days per week. Here, then, are two intermittent fasting strategies that have similar health benefits:

  • Time-restricted: eat lunch starting at 12 noon, and finish dinner by 8:00pm. Fast until the next day at noon (16 hour fast). Do this every day.
  • 5:2 fasting: fast for 2 different days each week, which means eating just 500-700 calories worth of food and drink on those days. Eat normally on the other 5 days.

The first strategy–a daily 16-hour fast–is the easiest, but its benefits might be equal to those of 5:2 fasting and the 3-day fast. (No study has directly compared these 3 fasting regimens.)

The benefits of intermittent fasting are numerous. As de Cabo and Mattson explain, they include
"[improvements in] blood pressure; resting heart rate; levels of HDL and LDL cholesterol, triglycerides, glucose, and insulin resistance.... In addition, intermittent fasting reduces markers of systemic inflammation and oxidative stress that are associated with atherosclerosis."
Fasting also helps with weight loss, for obvious reasons. Cutting out all snacks in the evening, which is the biggest change imposed by time-restricted fasting, means not only a reduction in calories consumed, but also a reduction in the amount of highly processed ("junk") foods in one's diet as well.

Furthermore, because intermittent fasting reduces inflammation, it may also improve symptoms of arthritis and even rheumatoid arthritis.

Why does fasting work? It's all about getting your body to switch over from glucose metabolism to ketone metabolism. Our usual 3-meal-a-day diet provides our body with a constant source of fuel in the form of glucose. Once that glucose is used up, though, our body switches to using fatty acids and ketone bodies. Ketone bodies provide more than fuel: as de Cabo and Mattson explain,
"Ketone bodies regulate the expression and activity of many proteins and molecules that are known to influence health and aging."
Ketone metabolism seems to bring a host of health benefits. The trick is getting our bodies to switch over to it, now and then. If we eat constantly, then our bodies happily subsist on glucose and never make the switch.

Does fasting truly reset your immune system? Six years ago, I concluded that a 3-day fast does the trick, at least partially. The science suggests that, if you can do it, a prolonged fast for 2-3 days will induce your body to clean out some old immune cells and switch on production of new ones. Now we're learning that intermittent fasting, which is easier to do, may work in much the same way, with multiple health benefits.

[Note: one of the authors of the NEJM study, Mark Mattson, is a Professor at Johns Hopkins School of Medicine, making him a colleague of mine. However, we are in different departments and we have never met.]

Let the 2010s be the end of the post-truth era

The 2010s are over, and the double-20s are about to begin. One phrase that I'd like to never hear again is "post-truth era," an idea that has gained prominence during the past decade, especially the last few years.

One dominant theme of post-truthery is that every person has a right to his/her own interpretation of the facts, and that these alternative interpretations–or "alternative facts," as Trump adviser Kellyanne Conway famously called them–deserve to be taken seriously. They don't.

And yet, like most of the pseudoscience that I've been writing about for years now, we have to continue calling out nonsense for what it is, because some of it is harmful, and even deadly. Politics is a never-ending font of post-truthery (or truthiness, as Stephen Colbert defined it in 2005), but here I'm concerned about science. Today I'll highlight three anti-truth campaigns that have caused great harm over the past decades, in the hope that they will soon fade away.

Among serious scientists, truth is not being questioned. Indeed, the essence of science is the search for objective truth. Sometimes, though, a scientific discovery threatens to undermine the power or profits of an influential industry, and that's when industry resorts to denialism (which is essentially the same thing as post-truthiness).

Perhaps the most well-documented example of organized science denialism dates back to the 1950s, when accumulating evidence made it clear that smoking causes cancer. The tobacco industry didn't want to admit this, even though their own internal research supported it, because it meant that their main product was killing their customers, which in turn was terrible news for their business. In response,
"the tobacco companies helped manufacture the smoking controversy by funding scientific research that was intended to obfuscate and prolong the debate about smoking and health." (Cummings et al. 2007).
Eventually, after decades of lawsuits and literally millions of smoking-related deaths, the industry was forced to admit the truth and pay out billions of dollars in settlements in the U.S. Nonetheless, many people still smoke, and even as recently as 2016, the largest tobacco company in the U.S., Philip Morris, was still trying to deny the science about cigarettes.

My second example is more recent, and potentially even more harmful to the human species. You might have already guessed it: I'm talking about climate change denialism. For several decades, the evidence has been building that the planet is getting warmer. A series of reports from the Intergovernmental Panel on Climate Change (IPCC) warned, in increasingly confident terms, that humans were the primary cause of recent warming, mostly due to our use of fossil fuels and the carbon they emit into the atmosphere.

The current IPCC report states unequivocally that humans have already caused 1° C of warming, and that the warming will increase rapidly over the next several decades.

Scientifically, these facts are not in dispute. The world is already experiencing more severe storms, unprecedented floods and droughts, and die-offs due to warming oceans (such as the massive and tragic die-off of coral in Great Barrier Reef).

However, the fossil fuel industry sees global warming as a threat to their profits. Rather than invest in new, cleaner forms of energy, large companies such as Exxon-Mobil and billionaire coal magnates such as the Koch brothers have poured countless millions of dollars into disinformation campaigns to cast doubt on the science of climate change. Prominent among these efforts is The Heartland Institute, a fossil-fuel-funded organization whose main mission is to cast doubt on the science of climate change. (Heartland has also worked to cast doubt on the link between smoking and cancer.)

Climate change denialists learned from the tobacco companies that it was possible to delay government action by decades, simply by casting doubt on the science. Unfortunately, their campaigns have been working. For years, many U.S. politicians denied that the planet was getting warmer. As that argument has become increasingly harder to make with a straight face, they've changed their strategy, and now they might admit that the planet is heating up, but deny that human activities are responsible. They're still wrong.

The goal of this denialism is, simply put, to protect the profits of fossil fuel industries. However, truth doesn't care if you believe it or not. The world is getting hotter. Australia just had its four hottest days in recorded history. The unprecedented heat wave has led to hundreds of fires through much of the country, threatening every major city on the continent. There's no reason to think this won't keep happening.

Climate change denialists are only fooling themselves–after being duped by oil and coal companies.

My third and final example is one that has frustrated me for 15 years now, and it's one that just won't go away: the anti-vaccination movement. This is one of the most frustrating examples of post-truth wrongheadedness, in part it seems so unnecessary, and because so many children have been harmed as a result.

First, let's be clear about the facts: vaccines are one of the greatest boons to human health in the history of science and medicine. People used to die by the millions from smallpox, polio, and a dozen other infections that are now almost completely preventable by vaccines.

Smallpox was 100% eliminated from the planet in 1980, in one of humankind's greatest public health triumphs. Polio has now been eradicated from nearly all countries, and a campaign that started in 1988 has now reduced polio to just a few countries and fewer than 100 cases worldwide. Both of these successes are due to vaccines.

Many other diseases, including measles, chicken pox, and bacterial meningitis, have been reduced so dramatically by vaccines that physicians in the U.S. and Europe almost never see a case. This graph shows the dramatic effect of the measles vaccine, which was introduced in the U.S. in the early 1960s:
Measles cases in the United States by year, 1954-2008. Source: CDC.
The graph shows the number of reported cases, but actual cases were much higher, likely around 4 million cases per year by one estimate. These are the facts.

So what happened? The modern anti-vax movement, led by a small number of extremely vocal, extremely self-confident individuals, began in 1998 with the publication of a fraudulent study (later retracted when the fraud was uncovered) claiming that vaccines caused autism. The study was led by former physician Andrew Wakefield, who later lost his medical license because of his fraud, which included misleading his co-authors and mistreating patients.

Nonetheless, this study was picked up and amplified by several celebrities with large followings, including former Playboy model and MTV host Jenny McCarthy and political activist Robert F. Kennedy Jr, the nephew of former US President John Kennedy. RFK Jr.

Anti-vax activism is all over the web today, despite many efforts to quash it. Countless claims of "my child got sick after his vaccine jab" are presented as proof that vaccines cause harm, and under post-truthism, we're supposed to take such claims seriously.

These stories can be especially difficult to respond to, because many parents are dealing with children who have genuine health problems–including autism–and the parents often truly believe what they are saying. Thus it won't do to tell them to be quiet and go away: their children really do need medical care. They're simply wrong in believing that vaccines have anything to do with their childrens' problems. Their beliefs are amplified by Facebook groups and websites whose sole purpose is to echo and amplify the mistaken claims of anti-vaxxers.

Even though there was never any good evidence that vaccines cause autism, scientists have conducted dozens of studies involving literally millions of children to answer precisely that question, and the evidence is very, very clear: vaccines do not cause autism, nor do they cause any other systematic neurological or behavioral problems. Vaccines do prevent diseases, though, and unvaccinated children can and will get sick. Recent experience has also given us, tragically, many examples of children who died from entirely preventable infections, because their parents didn't vaccinate them. These tragedies didn't have to happen.

Every era is the age of truth. The idea that we're in a "post-truth era," despite being repeated thousands of times in articles, essays, and op-eds over the past decade, is a commentary on people's ability to fool themselves, not on the state of the world. Truth describes the world as it is, and those who choose to deny it might win a short-term argument, but in the long term, they will always lose.

Finally, on a more positive note, I'm somewhat heartened by efforts to educate college students on how to recognize and counter bogus ideas, such as the University of Washington course, Calling Bullshit, created by Carl Bergstrom and Jevin West. (Yes, that really is its title.) As the professors wrote,
"The world is awash in bullshit.... We're sick of it. It's time to do something, and as educators, one constructive thing we know how to do is to teach people." 
If you're interested, they've made the lectures available as free videos on YouTube.

Labelling an era as post-anything has always, to me, suggested a lack of substance, as if the era is defined only by what came before it. The use of "post-" also ignores that fact that the next era will need a name too. Should we expect "post-post-truth" to come next, and what would that look like? Let's hope that the 2020s will give us a return to simple respect for truth. The future of civilization might very well depend on it.

Can the Apple Watch monitor heart health?

Can the Apple Watch accurately detect atrial fibrillation?

When I first heard that scientists were conducting a study to answer this question, I was deeply skeptical. A simple wrist device detecting heart arrhythmias? This seemed too simplistic to be possible.

But a new study, just published in the New England Journal of Medicine, lays out some pretty compelling evidence that the Apple watch can do just that.

Atrial fibrillation (or atrial flutter) is a type of irregular heartbeat that is the most common cardiac arrhythmia in the U.S., affecting some 6 million people a year. The NEJM article estimates that the lifetime risk for "a-fib" might be as high as 1 in 3. Atrial fibrillation isn't necessarily a problem on its own, but it can greatly increase the risk of strokes. Many people have episodes of a-fib without even being aware of them, which is why a simple, convenient way of detecting them could be medically valuable.

The Apple Watch study was truly enormous, with 419,297 subjects monitored for about 4 months. Only a company like Apple, with a popular product like its watch, can even hope to recruit this many people to join a study. The idea was pretty simple: use the Apple Watch to detect an irregular pulse, which might be sign of atrial flutter or arrhythmia.

During the course of the study, 2,161 subjects had at least one report of an irregular pulse, about 0.5% of the total. Each of these subjects was then sent an electrocardiogram (ECG) patch, which they were supposed to wear for several days to determine if they really were having arrhythmias.

Of course, not everyone wore the ECG patch as they were supposed to, but in the end, 450 subjects wore the ECG patch (for an average of about 6 days), filled in all the required questionnaires, and returned the patch for analysis. Among these subjects, 34% of them genuinely did have atrial fibrillation as confirmed by the ECG patch. Some of them had only brief episodes, but a subgroup had nearly continuous symptoms.

The study also tried to determine the false positive rate of the Apple Watch warnings–that is, how often did it report an irregular pulse when the subject was not experiencing a-fib or atrial flutter? The researchers evaluated all of the reports from watches that were being worn by people who also had an ECG patch. In this analysis, 71% of the irregular pulse reports from the watch corresponded to atrial fibrillation simultaneously measured by the ECG patch. The other 29% weren't normal either: three-fourths of those reports were due to "frequent premature atrial contractions."

So overall, the Watch was surprisingly accurate, with an impressively low false positive rate.

How does it work? Well, the back of the watch contains several sensors that detect light (photodiodes), along with green and infrared LEDs that emit light. As Apple's website explains,
"By flashing its LED lights hundreds of times per second, Apple Watch can calculate the number of times the heart beats each minute."
This works because your skin is partially transparent: as everyone knows, you can see some of your blood vessels underneath your skin. In addition to measuring blood flow, the watch can also measure electrical signals using electrodes on the back of the watch and on a small dial on the side of the watch, called the Digital Crown. Here's how Apple explains this:
"When you place your finger on the Digital Crown, it creates a closed circuit between your heart and both arms, capturing the electrical impulses across your chest."
In other words, it behaves like an ECG monitor on your wrist. The NEJM study didn't use this feature of the Apple Watch, which suggests that the watch could be even more effective as a heart monitor in the future.

The Apple Watch is far from perfect, though. For one thing, we don't know how many episodes of atrial fibrillation it missed. Only 0.5% of subjects had a report of irregular pulse, but we don't know how many of the remaining 99.5% had an episode that the watch didn't detect. The authors of the study pointed out that they weren't trying to measure the watch's sensitivity, and they emphasized that
"the absence of an irregular pulse notification does not exclude possible arrhythmias."
Another caveat is that the study was funded by Apple, although it was led by scientists at Stanford and included scientists from multiple other highly regarded universities and medical schools. The funding was clearly disclosed in the NEJM article.

On the other hand, using the Apple Watch is far easier than other currently available procedures for monitoring your heart. Patients who have episodes of arrhythmia are typically told to wear a heart-rate monitor for days or weeks at a time. This involves taping electrodes to half a dozen places on your body, all of which are connected by wires to a device (basically a cell phone) that records the readings and sends them to a monitoring company. These monitors are very expensive to operate, far more than the Apple Watch.

So despite its imperfections, the Apple Watch might be the vanguard of a new wave of lightweight, less intrusive devices for monitoring our health. The technology is only going to get better.

$3.7 million to study quack medicine at a leading cancer center

Sometimes I'm not sure whether the best response to pseudoscience is to ignore it, or to patiently try to explain why it's wrong, or to get mad.

This week I'm mad.

My anger and frustration was triggered by a tweet from Memorial Sloan-Kettering's Integrative Medicine account, shown here:
For those who don't know, Memorial Sloan-Kettering Cancer Center is one of the world's leading cancer centers, both for treatment and research. If you are diagnosed with cancer, MSK is one of the best places to go.

But not everything at MSK is world class. Unfortunately, they have an "integrative medicine" center that offers a mixture of therapies ranging from helpful to benign to useless. One of their biggest activities is acupuncture, which they claim offers a wide range of benefits to cancer patients.

The MSK tweet shown here was boasting about a new, $3.7 million study funded by NIH to study the effect of acupuncture on pain that cancer patients experience from chemotherapy and bone-marrow transplants.

Here's why I'm mad: cancer patients are extremely vulnerable, often suffering the most frightening and difficult experience of their lives. They are completely dependent on medical experts to help them. When a place like MSK suggests a treatment, patients take it very seriously–as they should. But they really have no choice: a cancer patient cannot easily look for a second opinion, or switch hospitals or doctors. Even if they have the money (and cancer treatment is extremely expensive), switching hospitals might involve a long interruption with no treatment, during which they could die, and it might also involve traveling far from their home.

Offering these patients ineffective treatments based on pseudoscience–and make no mistake, that's what acupuncture is–is immoral. Now, I strongly suspect that the MSK's "integrative medicine" doctors sincerely believe that acupuncture works. Their director, Jun Mao, is clearly a true believer, as explained in this profile of him on the MSK website. But that doesn't make it okay.

I've written about acupuncture many times before (here, here, here, and here, for example), but let me explain afresh why it is nonsense.

Acupuncture is based on a pre-scientific notion, invented long before humans understood physiology, chemistry, neurology, or even basic physics, which posits that a mysterious life force, called "qi," flows through the body on energy lines called meridians. As explained in this article by MSK's Jun Mao:
"According to traditional Chinese medicine ... interruption or obstruction of qi was believed to make one vulnerable to illness. The insertion of needles at specific meridian acupoints was thought to regulate the flow of qi, thus producing therapeutic benefit."
Today we know that none of this exists. There is no qi, and there are no meridians. In that same article, Jun Mao continued by admitting that
"the ideas of qi and meridians are inconsistent with the modern understanding of human anatomy and physiology."
And yet this is what they offer to patients at MSK.

Just to be certain, I read one of the latest studies from MSK, published early this year, which claims to show that acupuncture relieves nausea, drowsiness, and lack of appetite in multiple myeloma patients who were going through stem cell transplants.

It's a mess: totally unconvincing, and a textbook case of p-hacking (or data dredging). The paper describes a very small study, with just 60 patients total, in which they measured literally dozens of possible outcomes: overall symptom score at 3 different time points, a different score at 3 time points, each of 13 symptoms individually, and more. I counted 24 different p-values, most of them not even close to significant, but they fixated on the 3 that reached statistical significance. The two groups of 30 patients weren't properly balanced: the sham acupuncture group started out with more severe symptoms according to their own scoring metric, and Figure 2 in the paper makes it pretty clear that there was no genuine difference in the effects of real versus sham acupuncture.

But they got it published (in a mediocre journal), so now they point to it as "proof" that acupuncture works for cancer patients. This study, bad as it is, appears to be the basis of the $3.7 million NIH grant that they're now going to use, they say, in "a larger study in 300 patients to confirm these previous findings."

And there you go: the goal of the new study, according to the scientists themselves, is not to see if the treatment works, but to confirm their pre-existing belief that acupuncture works. Or, as one scientist remarked on Twitter, "they already have a result in mind, the whole wording of this suggests that they EXPECT a positive outcome. How did this get funded exactly?"

Good question.

So I'm mad. I'm mad that NIH is spending millions of dollars on yet another study of a quack treatment (acupuncture) that should have been abandoned decades ago, but that persists because people make money off it. (And, as others have explained in detail, acupuncture is actually a huge scam that former Chinese dictator Mao Zedong foisted on his own people, because he couldn't afford to offer them real medicine. For a good exposé of Chairman Mao's scam, see this 2013 Slate piece.)

But I'm even more upset that doctors at one of the world's leading cancer centers are telling desperately ill patients, who trust them with their lives, that sticking needles into their bodies at bogus "acupuncture points" will relieve the pain and nausea of chemotherapy, or help them with other symptoms of cancer. I'm willing to bet that most MSK doctors don't believe any of this, but they don't want to invest the time or energy to try to stop it.

(I am somewhat reassured by the fact that MSK's Twitter account has nearly 75,000 followers, while it's integrative medicine Twitter account has just 110.)

Or perhaps they are "shruggies": doctors who don't believe in nonsense, but figure it's probably harmless so they don't really object. To them I suggest this: read Dr. Val Jones's account of how she too was a shruggie, until she realized that pseudoscience causes real harm.

And finally, let me point to this study in JAMA Oncology from last year, by doctors from Yale, which looked at the use of so-called complementary therapies among cancer patients. They found that
"Patients who received complementary medicine were more likely to refuse other conventional cancer treatment, and had a higher risk of death than no complementary medicine."
And also see this 2017 study from the Journal of the National Cancer Institute, which found that patients who used alternative medicine were 2.5 times more likely to die than patients who stuck to modern medical treatments.

That's right, Memorial Sloan-Kettering: patients who use non-traditional therapies are twice as likely to die. That's why I'm mad. This is not okay.