Doctors have understood for some time that it was inevitable. The American Cancer Society acknowledged today that cancer screening has been oversold.

It seems like every day you read in the newspaper that what was standard medical care yesterday is now no longer recommended. Don’t doctors know anything? Well, actually they do. And what seems like paradoxical behavior, no longer recommending aggressive screening for certain cancers, actually represents a more sophisticated understanding of the way in which cancer behaves.

The classic understanding of cancer is that once a cancer forms it will continue to grow steadily until it kills the patient. Cancer was viewed as if it were an infectious disease like syphilis. It starts small and easy to treat, may remain hidden for long periods of time, but eventually spreads to other parts of the body becoming incurable along the way. If cancer did indeed spread like that, the aggressive screening programs would make perfect sense.

But decades of research and clinical experience have led to a more sophisticated understanding of cancer. It has always been known that cancers from different parts of the body behave in very different ways. Ovarian cancer is extremely aggressive, while basal cell cancer of the skin grows very slowly. Breast cancer can and does spread to bones and brain, while colon cancer is most likely to spread only to the liver.

More recently we’ve learned that each cancer can be broken down into different subtypes, some more aggressive than others, and some better treated with one regimen instead of another. For example, breast cancers are now analyzed for the presence of hormone receptors on the outside of the cancer cells. The presence or absence of certain receptors tells us whether specific treatments will be helpful or useless, making it easier to target the cancer with the treatment most likely to work.

We have also learned that some cancers follow the model of an infectious disease like syphilis, starting small and curable and ending up throughout the body and incurable, many do not. Some cancers start small and explode aggressively. Others start small and stay small for decades. This more sophisticated understanding is a direct result of being able to diagnose cancer earlier. We now have a much better and far more nuanced understanding of the natural history of various cancers. It has become apparent that rather than finding all cancer, we need only find cancers that are aggressive and can ignore those that are known to grow very slowly if at all.

What’s the big deal? Isn’t cancer screening beneficial regardless of the natural history of the particular cancer? No, it’s not and therein lies the reason for the American Cancer Society’s call for less screening of certain cancers.

The goal of cancer screening is and has always been to reduce cancer deaths and disability, and therefore, that’s how cancer screening should be judged. By that standard, some forms of screening are total successes. For example, the Pap smear, the screening test for cancer of the cervix, has been an unalloyed bright spot in the war against cancer. The test is inexpensive and reliable, the follow up test to actually diagnose cancer (biopsies of the cervix) is harmless, and very few if any women are treated unnecessarily. Screening for cervical cancer saves many lives and has few long term side effects.

By the same standard, prostate cancer screening has been a terrible disappointment. The PSA blood test, the screening test, is notoriously unreliable. Even more problematic is the fact that many prostate cancers grow extremely slowly and are unlikely to spread. Most problematic is that the treatment has very serious side effects, impotence and incontinence. Screening for prostate cancer with the PSA test (and finding tiny cancers) saves no more lives than screening with a prostate exam (which can find cancers that are somewhat larger) and leaves many men with unnecessary long term side effects.

Whereas every cervical cancer is probably dangerous to the patient and the treatment has few long term side effects in any case (since cervical cancer is most commonly diagnosed in women who have completed childbearing), most prostate cancers are not dangerous to the patient and the treatment is often undertaken unnecessarily. It’s bad enough to endure impotence and incontinence as the side effect of life saving treatment. It is tragic to endure it as the side effect of unnecessary treatment.

Breast cancer is similar to prostate cancer. While frequent mammography is more likely to diagnose cancer, there has not been a corresponding decline in breast cancer deaths. Treating many more women with chemotherapy, lumpectomy and mastectomy has produced very few additional lives saved.

The solution to this conundrum, of course, is to develop more sophisticated screening tests, tests that can discriminate between life threatening cancers and non-life threatening cancers. In the meantime, the existing screening tests should be judged on their ability to save lives, not on their ability to diagnose cancer, since many cancers don’t need to be treated.

Screening everybody for everything and screening them often is a very blunt tool that seemed appropriate when we had an unsophisticated understanding of cancer. Now that our understanding of cancer has deepened, the use of screening tests should reflect our new knowledge.

Simply put, screening tests should be reserved for situations in which they save lives. Dialing back on screening tests is not a step backward, it is a step forward in treating only those who need to be treated and not harming anyone else in the process.

I blog in a variety of places with a variety of different audiences, but I am struck by the uniformity of the arguments of vaccine rejectionists. It’s not surprising, though, when you consider that they are not reaching their conclusions independently, but rather regurgitating seemingly “impressive” arguments they have read on vaccine rejection websites.

The latest such “argument” is that the safety and efficacy of vaccines have never been proven because they have not been subjected to a controlled randomized double blind study against a placebo. This “argument” is designed to impress those with a minimal knowledge of statistics. In other words, it is designed to impress those who know enough statistics to realize that anecdotes are not a substitute for scientific studies and are familiar with the concept that a controlled randomized double blind study against a placebo is the “gold standard” in some areas of drug research.

Unfortunately, they don’t know enough to realize that controlled randomized double blind studies are unethical in certain circumstances, including the testing of vaccines. So what is presented on vaccine rejection websites as a startling and inexplicable refusal of scientists to test vaccines is actually the inevitable result of complying with ethical rules for scientific investigations.

There are many situations in which controlled randomized double blind studies are unethical. Consider infant carseats:

Do carseats minimize the risk of injury and death of infants?

There never been a controlled randomized double blind study of carseats. Why not? Because it is unethical to randomize some infants to be unbelted in cars simply so we can check how many will be injured and die.

Does that mean we don’t know if carseats reduce the risk of injury and death? Of course not. There are a myriad of statistical investigations that allow us to determine whether carseats reduce injury and death, including large scale population studies, retrospective cohort studies and many others.

So the fact that there are no controlled randomized double blind studies of vaccines is a red herring. It works only on those who don’t understand science and statistics. On them, of course, it works very well.

Vaccine rejectionists, like many Americans, simply don’t understand statistics. This is a serious problem because Americans are exposed to a tremendous amount of statistical information and are required to make many decisions based that information.

An article in the journal Public Understanding of Science explains:

We live in a statistics-rich society: statistics permeates many aspects of life—from media, health, and work to citizenship. In the media, we can observe a growing emphasis on statistical results. This is particularly the case in health and medical reporting which tend to be the most compelling scientific issues for citizens … The understanding of these statistical components is crucial to help citizens participate in public debate and arrive at political decisions.

Statistical misunderstandings are very common and lead to cynicism about science and medicine.

Statistics requires the ability to consider things from a probabilistic perspective, and to employ quantitative technical and abstract concepts such as significance, margin of errors, and representativeness. Since these concepts are difficult to understand, statistical misunderstandings can often be observed in the everyday but also in the media and research results. It is important to clear up these misunderstandings, as they lead to the misuse of study results, and the development of a distrustful or cynical attitude toward statistics.

Vaccine rejectionists, you’ve been tricked … again. How many times do you have to be tricked before you realize that you are being victimized by your lack of knowledge of science and statistics?

N.B. I’ve closed the comments for this thread because it is in danger of crashing the site. Feel free to continue the discussion at The extraordinary conceitedness of being an anti-vaxxer.

Sometimes the best way to understand a situation is to see a graphical representation of it.

Below is a graph of pediatric influenza deaths over the past 4 years. I have adapted it from a graph created by the CDC that can be found here. The graph shows the number of pediatric deaths each week for the past 4 years. The green bars represent seasonal flu deaths; the pink bars represent deaths from confirmed H1N1 influenza.

The graph represents in the starkest possible way the difference between the H1N1 flu and the seasonal flu.

Seasonal flu can and is fatal in some children. Each year, primarily from February to May, some children will die of the seasonal flu.After that, pediatric deaths typically drop off to almost zero until the next flu season.

Something entirely different happened this year. Not only did flu deaths not drop off, but H1N1 flu is claiming children in higher numbers than the seasonal flu ever did. The graph does not show it, but unlike the children who die of seasonal flu who typically suffer from underlying medical conditions, healthy children are also dying of the H1N1 flu.

Could the H1N1 flu still burn out? Certainly that could happen, but there is no evidence that the tide has turned. Based on the fact that incidence of the flu typically rises dramatically in the winter, we are on track for an especially deadly flu season.

We could wait and see what happens, or we can attempt to head off disaster with a vaccination program. Look at the graph. What would you do?

Healthcare conspiracies are powerful and long lived. How can we combat health conspiracies among people who don’t understand or don’t believe scientific evidence? I suggest a simple expedient. Insurance companies should refuse to pay for vaccine preventable illness and their complications.

Why are health conspiracies resistant to scientific evidence?

All health care conspiracies — vaccine rejectionism, claims that conventional medicine is suppressing inexpensive alternative “cures”, the insistence that obstetricians want to ruin women’s birth experiences — share one critical feature. They are unfalsifiable. They can never be proven wrong by factual evidence because conspiracy theories predict that there will be reams of evidence contradicting their claims, but that evidence is itself part of the conspiracy.

Basham in the paper Living with Conspiracy published in the Philosophical Forum, Fall 2001, offers a definition of conspiracy:

A “conspiracy theory” is an explanation of important events that hypothesized the intentional deception and manipulation of those involved in, affected by, or witnessing these events… [T]hese deceptions and manipulations are usually thought to express nefarious, even insanely evil, purposes.

Best of all, the conspiracy theory can never be proven wrong:

…[B]ecause conspiracy theorists naturally invoke the idea that the official explanations are in part or whole deceptions, they can rationally interpret evidence against their accounts — official reports, public statements and court of law testimonies … — as evidence for the conspiracy. Falsified evidence is precisely what a conspiracy theory predicts will be produced by the government and other players in ample amounts…

It’s an absolutely brilliant tactic. The vaccine rejectionist responds to the copious evidence against the claim that the government is deliberately poisoning people with vaccines by declaring that the massive amount of evidence proves that there is a conspiracy by the government to poison people with the vaccine. Only a nefarious actor could assemble such overwhelming evidence. The sheer volume of the evidence demonstrates that the evidence is manufactured as part of the conspiracy.

The unfortunate consequence is that it is impossible to show a conspiracy theorist that he is wrong. All evidence, whether bolstering his claims or undermining them, is viewed as supportive evidence of something. It either supports the claim of harm, or if not, supports the existence of the conspiracy to do harm.

Perhaps we should stop trying to prove anything to health conspiracy theorists. Instead, we should let them live with the consequences of their decisions. I have a modest proposal:

In the case of vaccinations, insurance companies should deny coverage for vaccine preventable diseases and their complications in anyone who did not get the recommended vaccinations.

If vaccinations are worthless or harmful, vaccine rejectionists have nothing to worry about. They will never have to pay because they won’t get sick. On the other hand, if they are wrong, they mistake will be illuminated in a way that is very easy to understand; they will literally have to pay for it.

On the face of it, suspicion of the new H1N1 vaccine is incomprehensible. Vaccination has been one of the biggest lifesavers of the past 200 years. It is the cornerstone of public health, directly responsible for the dramatic drop in infant and child mortality and the dramatic extension of lifespan we have enjoyed over the last century. Despite countless conspiracy theories advanced by vaccine rejectionists in the past 200 years, not a single one has turned out to be true.

True, there are side effects, some serious. However, serious vaccine side effects like brain damage or death are so rare as to be measured per 100,000 people or per 1,000,000 people. There has been no effort to hide these serious side effects. Indeed parents are required to sign consent forms acknowledging the risk of serious side effects before their children can be vaccinated.

So why are people suspicious of vaccines? There are many reasons including the American love for conspiracy theories, the public campaigns led by prominent celebrities, and the desire to assign causes to diseases like autism where the cause remains unknown. The most important cause of the suspicions, though, is one that is very easy to address. Most people don’t know how vaccines work.

To understand how vaccines work, you need to understand how the body defends itself from bacteria and viruses. Just like the body has a dedicated system to digest food (the gastrointestinal tract) or to remove waste products (the kidneys and urinary tract), the body also has a dedicated system to fend off bacteria and viruses; it’s called the immune system.

The body actually has three layers of defense against bacteria and viruses. The first is the physical barrier presented by the skin or the lining (mucous membranes) of interior passages like the mouth and nose. Although we are surrounded at all times by bacteria and viruses, most of them never make it beyond the skin. Of course the integrity of the skin and mucous membranes can be disrupted by a cut or puncture, allowing bacteria or viruses to be introduced directly into the body.

The second line of defense is a non-specific immune response. If bacteria colonize a cut on your hand, your body reacts in a predictable way. There will be swelling, redness, and pain, a response that does not depend on the identity of the threat. Special immune cells will race to the site and engulf the offending bacteria. When they die in the attempt, they accumulate as pus.

Even primitive animals have non-specific immune responses, but higher animals and human beings have an additional, more powerful response. We can produce antibodies. Antibodies are proteins that recognize specific bacteria or viruses and bind to them, thereby signaling to other immune cells that they are targets for swift neutralization. Each antibody binds to a specific site on a specific bacteria or virus.

We’re not born with those antibodies, though. We make them in response to a threat. For example, we are not born with antibodies to the chickenpox (varicella) virus. When exposed to the varicella virus, though, we can learn to make antibodies to it. It takes time, but gradually we can produce enough antibodies to fend off the disease.

Unfortunately, we don’t always get the time we need. We can make antibodies to smallpox, for example, but many individuals are overwhelmed and killed by the virus long before they could make enough antibodies to fend it off. Those who do win the race and manage to produce enough antibodies to survive are now permanently protected. That’s because the immune system retains the ability to make the specific antibodies against the smallpox virus. Whereas it may take days to produce smallpox antibody when first exposed, a second exposure will be met with rapid and massive production of antibody, generally preventing the individual from getting sick at all.

So in order to be protected from the disease, you had to get the disease, and you might die before you were able to make enough antibody to protect yourself. Imagine, though, if you could learn to make the protective antibodies without actually getting sick. That’s the theory behind vaccines.

In order to make antibodies to a virus (or bacterium) the body need to “see” the virus. In other words, it needs to have direct exposure to the virus, but that virus doesn’t have to be functional, and it doesn’t even have to be whole. A virus can be inactivated (live attenuated) or killed and still produce an immune response. It can also be broken down into its constituent parts and the parts can produce an immune response. Any future exposure to the live virus (though contact with others who have the disease) will be met with rapid and massive production of antibody, preventing the individual from getting sick at all. A vaccine is merely and inactivated or dead form of the virus, letting you learn to make antibody without getting sick in the process.

Vaccines do not produce perfect immunity. The dangerous part of the virus might be the part that evokes the most powerful immune response. Rendering the virus harmless by inactivating it, killing it or breaking it up, may remove that part and the immune response to the less dangerous parts might be weaker. So actually getting the disease may produce a better immune response than the vaccine … but only if you survive the disease.

Successfully fighting off a disease depends on being able to produce enough antibody before the disease kills you. Until vaccines, the only way you could learn to produce antibody was to actually get the disease. Now, instead, you can learn to make antibody by being exposed to a harmless form of the virus or bacterium.

Feminist scholar Michele Crossley’s recent paper in the journal Feminism Psychology raises important questions about breastfeeding, and by extension, about unmedicated childbirth. Breastfeeding as a Moral Imperative: An Autoethnographic Study makes a controversial claim:

…[F]ar from being an ’empowering’ act, breastfeeding may have become more of a ‘normalized’ moral imperative that many women experience as anything but liberational. Accordingly, an uncritical appropriation of the idea that ‘breast is best’ may not only be disempowering for women, but also problematic for babies.

Crossley begins by exploring the place of breastfeeding within our culture:

Many contemporary social movements … highlight the risks associated with modern technology with the consequence that the rhetoric of the ‘natural’ has proliferated… This whole idiom of the ‘natural’ has surrounded childbirth and child-rearing and has been a key theme in the ‘alternative birth movement.’ As Oakley argued, ‘like natural childbirth, natural infant feeding has become fashionable in a society that is technological “by nature”‘.

…[B]reastfeeding has been associated with women’s personal agency and empowerment. The promotion of breastfeeding has constituted part of an attempt to ‘demedicalize’ life events (such as pregnancy) and to return such processes to the ‘rightful moral domain under the control of women themselves.’

Crossley’s paper isn’t really a study. It’s just a description of her personal experience, which has led her to re-evaluate the rhetoric she previously accepted. Like many white, Western, well off women, Crossley uncritically embraced the bizarre notion that there is a “right way” to give birth and to “bond” with a newborn:

Related to my desire to establish a strong ‘bond’ was my desire for a ‘natural’ childbirth. I had read that if a delivery entails a lot of intervention, then the baby emerges into the world potentially traumatized by the effects of drugs and bright lights, all of which make the bonding process more difficult…

In preparing for labour, I totally discarded any notion of interventions such as a caesarean … After over fourteen hours of labour, when the baby was eventually delivered by emergency caesarean section … the first thing I remember was that I ‘had to get that baby to the breast’. Because I had not had the opportunity to bond at the moment of birth as I had been anticipating, it made me all the more determined to ensure that breastfeeding happened in the way I wanted.

But the actual experience of breastfeeding was nothing like she had been led to believe. From the very beginning, the baby did not appear to be getting enough milk. Despite growing evidence that the baby was failing to thrive (his weight had fallen from the 75th percentile at birth to the 5th percentile at 10 weeks), and desperate entreaties by the baby’s father, Crossley refused to relinquish the fantasies promoted by breastfeeding advocates.

…The message that had been ‘drilled into’ my head at the antenatal classes and from the books I had been reading was that ‘you always produce enough breastmilk’, ‘breastfeeding is a perfect system’. In fact, I had even asked the health visitor at the time if the baby’s constant screaming could be explained by the fact that he wasn’t getting enough milk. Her response was that ‘you always produce enough breastmilk, always, there’s always enough …’

The baby’s father became frantic:

…I had to confront you about the breastfeeding. I felt at that point that we were gonna kill him or do him some serious damage … and I just thought he is not gonna survive this. I felt as if I was, I suppose, I was the only person who could see this …

They began bottle feeding the baby and he began to thrive. Crossley, however, was torn by feelings of guilt and shame:

I felt like a failure because … I had ‘taken on board’ the message that breastfeeding was really difficult, it was hard work and ‘many people didn’t manage to do it’. One had to be ‘really determined’ to succeed, but if ‘you tried really hard, you could manage it’… [M]y experience was entirely consistent with a woman in Lee and Furedi’s study who commented that women who ‘succeed at breastfeeding are made to feel like it’s such an achievement, they have done so well, they deserve a medal…’ As Lee and Furedi argue, some women have come to view breastfeeding as a ‘measure of motherhood and consciously or unconsciously judge other mothers accordingly’…

Crossley’s personal experience has led to an epiphany:

…[A]s with other health-related behaviours, the act of breastfeeding can become inextricably interrelated with the construction of identity and the creation of a sense of morality, values and orientation to ‘the good.’

[T]he act of breastfeeding came to symbolize all that was important about being a ‘good’ mother. It meant ‘bonding’ and forming emotional connections, ‘being there’ for the infant, learning to ‘go with the flow’, ‘letting go of the instinct to control’ and ‘learning to trust in one’s own body’. Dykes has previously characterized this understanding of breastfeeding as deriving from the ‘natural’ discourse that has been popularized in recent years.

Crossley concludes:

Breastfeeding, far from being the ‘resistant’ body-project that advocates of demedicalization and ‘women-centred’ alternatives originally promoted, may have become more of a ‘normalized’ moral imperative that some women experience as anything but liberational …

Sarah Palin’s assertion that healthcare reform would bring “death panels” empowered to kill sick people in order to save money is pure fantasy, but the idea resonated with the American public. It speaks to people’s deepest fears, that when they are frail and ill, society will take the opportunity to do them in. The irony is that the fear is entirely misplaced. They don’t need to worry that the healthcare system will kill them deliberately; they should be worried that the healthcare system will kill them accidentally.

It is difficult to deliberately die within the American healthcare system. Far from convening “death panels” to withdraw care, providers and hospitals are ignoring the wishes of those who want to die. Advance directives and healthcare proxies have allowed Americans to forgo care at the end of life, yet the majority of these arrangements are ignored, primarily because of fear of lawsuits, and often in the face of intra-family conflicts.

Unfortunately, it is all too easy to die by accident within the American healthcare system. Although claims that “doctors are a leading cause of death” are vastly exaggerated, the number of healthcare errors is extraordinarily high, and the death toll from those errors is far too large.

Dr. Donald Berwick of the Institute for Healthcare Improvement detailed the experience of his wife Ann, hospitalized for a rare spinal problem:

An attending neurologist said one drug should be started immediately, that “time is of the essence.” That was on a Thursday morning at 10 a.m. The first dose was given 60 hours later, on Saturday night at 10 p.m… One medication was discontinued by a physician’s order on the first day of admission and yet was brought by a nurse every single evening for 14 days straight. “No day passed–not one–without a medication error,” Berwick remembers… “The errors were not rare. They were the norm.”

After he publicized his experiences, Berwick was besieged by other doctors saying, “If you think that’s terrifying, wait until you hear my story.” One distinguished professor of medicine whose wife was hospitalized in a great university hospital was too frightened to leave her bedside. “I felt that if I was not there, something awful would happen to her,” he told Berwick. “I needed to defend her from the care.”

The problem first received widespread attention with the publication of Dr. Lucian Leape’s paper in JAMA in 1994, Error in Medicine:

Autopsy studies have shown high rates (35% to 40%) of missed diagnoses causing death. One study of errors in a medical intensive care unit revealed an average of 1.7 errors per day per patient, of which 29% had the potential for serious or fatal injury. Operational errors (such as failure to treat promptly or to get a follow-up culture) were found in 52% of patients in a study of children with positive urine cultures.

Given the complex nature of medical practice and the multitude of interventions that each patient receives, a high error rate is perhaps not surprising. The patients in the intensive care unit study, for example, were the recipients of an average of 178 “activities” per day. The 1.7 errors per day thus indicate that hospital personnel were functioning at a 99% level of proficiency. However, a 1% failure rate is substantially higher than is tolerated in industry, particularly in hazardous fields such as aviation and nuclear power…

It is hardly surprising that errors have become a prominent feature of a system designed to “process” as many patients as possible, as quickly as possible. Doctors are being compelled to see more patients in less time, despite the fact that many more people are living with complex medical conditions. Nurses are compelled to care for many more patients at one time, despite the fact that their medical needs, particularly the need for sophisticated monitoring technology, have grown dramatically, and the patients themselves are sicker.

Most importantly, in an industry where mistakes are a matter of life and death, the underfunding of medical care means that hospitals do not have the money to acquire technology that can reduce errors.

In an update of his report on medical errors published earlier this year, Dr. Leape explains:

Errors and injuries can, in fact, be prevented by redesigning systems to make it difficult, and sometimes impossible, for caregivers to make mistakes. A classic example is the elimination of accidental (fatal) intravenous injections of concentrated potassium chloride by removing the medication from the nursing units and requiring it to be added to intravenous solutions when they are prepared in the pharmacy.

Another example is computerized physician order entry systems (CPOE), where the physician must enter all orders, including all prescriptions for medications, by computer. This ensures that the order is complete, it is not a medication the patient is allergic to, and that the dose is within usual limits… CPOE can reduce serious medication errors by 60–80%.

The healthcare system as it currently exists unwittingly conspires to increase errors. When it comes to medical errors, we should take Dr. Leape’s most important insight to heart:

We need to move from looking at errors as individual failures to realizing they are caused by system failures. This is the driving principle.

The ultimate irony of Sarah Palin’s “death panel” fabrication is that healthcare reform represents the best chance of reducing medical errors, while opposing healthcare reform virtually insures that medical errors will continue apace. No one should worry about being killed deliberately by a “death panel” but everyone should fear being killed accidentally by a medical error.

Vaccinations have been around for over 200 years and vaccine rejectionists have been around for nearly that long. Over the years, the basis for claims of harm from vaccines have changed, but one factor has remained constant. Vaccine rejectionists have never been right. The current fear mongering surrounding thimerosal is just the latest iteration in an ongoing effort. That fear mongering rests on two factors, ignorance of basic chemistry and ignorance of the existing research on thimerosal.

To hear vaccine rejectionists tell it, all mercury containing compounds are dangerous and therefore thimerosal is dangerous. But that’s not how chemistry works. The toxicity of a substance depends on how atoms are arranged, not simply which atoms are present. The fact that some mercury compounds are dangerous does not mean that thimerosal must be dangerous because it contains mercury.

Consider the example of sodium. Sodium is both poisonous and explosive. That does not mean that compounds that contain sodium are either poisonous or explosive. Table salt (sodium chloride) contains sodium, yet we do not worry that salting our food will result in an explosion at the dinner table.

Similarly, mercury is poisonous, but that does not mean that any compound that contains mercury is also poisonous. Some mercury containing compounds, like methyl mercury, are poisonous. Methyl mercury is the found in fish and is the reason why restrictions of fish consumption are recommended for certain groups. Thimerosal is ethyl mercury and is not poisonous.

Though methyl mercury and ethyl mercury might sound like they are very similar, one is poisonous and the other is not. How can that be? Consider the case of alcohol. Methyl alcohol (methanol), also known as wood alcohol, will lead to blindness or death if you drink it. Ethyl alcohol (ethanol) is the alcohol found in wine and spirits. Chemical structure is more important than the identity of the individual atoms that make up the compound.

The safety of thimerosal is more than simply theoretical. Contrary to the claims of vaccine rejectionists, thimerosal has been studied extensively in large populations. There have been many studies that demonstrate the safety of thimerosal.

Consider the study Thimerosal exposure in infants and developmental disorders: a retrospective cohort study in the United Kingdom does not support a causal association (Andrews et al. Pediatrics 114. 584-591.2004). This was a retrospective cohort study was performed of 109 863 children who received thimerosal containing DPT vaccines. The study found no evidence that thimerosal caused developmental delays.

Thimerosal exposure in infants and developmental disorders: a prospective cohort study in the United kingdom does not support a causal association (Heron et al. Pediatrics 114. 577-583.2004) followed 14,000 children for up to 7+ years. The authors found:

Contrary to expectation, it was common for the unadjusted results to suggest a beneficial effect of thimerosal exposure. For example, exposure at 3 months was inversely associated with hyperactivity and conduct problems at 47 months; motor development at 6 months and at 30 months; difficulties with sounds at 81 months; and speech therapy, special needs, and “statementing” at 91 months… CONCLUSIONS: We could find no convincing evidence that early exposure to thimerosal had any deleterious effect on neurologic or psychological outcome.

The bottom line is that the vaccine rejectionists are wrong once again. The fact that thimerosal contains mercury does not mean it is dangerous because the chemical structure determines the danger, not the identity of the individual atoms. More importantly, thimerosal has been studied extensively in large populations over time and has been demonstrated repeatedly to be safe.

I’m torn.

I can’t decide whether it was greed or stupidity that led the American Academy of Family Physicians to accept a corporate sponsorship from Coca Cola.

Greed is certainly behind the AAFP decision to create its “Consumer Alliance program.” I love the Orwellian title! AAFP is not allying with consumers. It is partnering with businesses. The businesses will provide money and the AAFP will provide legitimacy. Yet said AAFP President-elect Lori Heim, M.D. disingenuously claims:

The Consumer Alliance program is a way of working with interested companies to develop educational materials to help consumers make informed decisions so they can include the products they love in a balanced diet and healthy lifestyle.

No, it isn’t. The Consumer Alliance solicits money from corporate sponsors to enrich the AAFP coffers.

A partnership with Coca Cola defies comprehension. The American Academy of Family Physicians has been out front in calling attention to the link between soft drinks and obesity, particularly childhood obesity.

Soft drink consumption has increased dramatically in recent decades. The increase corresponds with the rise in obesity and diabetes in the United States. Some evidence suggests that sugar-sweetened beverages increase the risk of childhood obesity. No study has shown that these drinks increase the risk of diabetes, although this relationship is plausible not only because of the added sweeteners but also because the caramel coloring may increase insulin resistance.

The official position of the AAFP is to minimize Coke consumption; the official position of Coca Cola is to maximize Coke consumption. In fact, everything the Coca Cola Company does is designed to maximize Coke consumption and, therefore, profits. If they are giving money to the AAFP it is because they believe that the legitimacy they will gain in exchange will lead to increased profit. The conflict of interest could not possibly be more stark.

I suppose it shouldn’t matter how much you are asking for your soul when you auction it off, but I find it galling that the AAFP had sold its soul so cheaply. AAFP President-elect Heim says the payment “in the strong six figures.” In other words, it took less than a million dollars to convince the AAFP to ally with a purveyor of a product does not improve health and may actually impair it.

The AAFP has clearly learned nothing from the example of other medical organizations that have compromised their credibility with inappropriate corporate sponsorships. The American Medical Association suffered a major blow when forced to renounce a partnership with Sunbeam, a maker of home electronics. According to Quackwatch:

…[T]he American Medical Association announced that it would pay $9.9 million to the Sunbeam Corporation to settle a breach-of-contract suit… The suit was filed … after the AMA announced it would not honor an exclusive 5-year royalty agreement under which the AMA logo would have been placed on Sunbeam’s “Health at Home” products, which included heating pads and humidifiers. The endorsement plan, … had no requirement that the AMA test the products… An investigative report on the management decisions leading to the contract led the AMA’s chief executive officer and two other top AMA executives to resign.

The AMA has never fully recovered from the scandal and has seen its membership drop to less than one third of American physicians.

The American Academy of Family Physicians has made a terrible mistake. It has compromised its integrity and credibility by accepting money from Coca Cola. It should follow the example of the AMA and renounce the partnership. President-elect Heim has managed to besmirch the reputation of the organization even before taking office. Hopefully it is not too late for her to undo the damage.