81st Skeptics' Circle

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“Big” Pharma Marketing

Doctors need to navigate with care

Much of alternative medicine makes dubious assumptions about the world of healing that set it apart from the real world. In essence, this makes it an untenable world view- at least scientifically speaking- and simply a non-starter. On the other hand, that’s not to say these methods have nothing to offer or teach us. Many of these modalities claim to “reach” people because they tend to cater to clients needs. Though, they often go too far, there is a germ of truth to these claims. By attempting to co-opt very real human social needs –empathy for example- they have in some way helped direct attention to important social aspects of human interaction.

The previous post touched on some of the more nuanced qualities of the “human” side of medicine and how important it is to understand and be aware of the complexities of social interactions –networking- and how it can impact health. It plays into the “art and science” of medicine and reminds us that it is a uniquely human endeavor.

Though it is difficult to wrestle with these issues, it is just as important to consider them as it is to debunk the non-science and falsehoods of alternative methods. This brings us to a related theme regarding the effect of networking.

It’s not a stretch to note that the state of medicine today is full of structural and foundational problems (i.e.; health care distribution, client/doctor relations). For example, pharmaceutical companies can make practicing science and evidence based medicine more challenging than it should be. Market pressures, commercial demands, and fierce competition within the industry create a need to vie for each and every costumer -in this case doctor- and can drive their therapeutic choices to some degree.

Here is where ugly “big pharma” conspiratorial accusations begins to bubble up out of the woodwork and out of many peoples mouths. Indeed there may be shades of this occuring. However, this probably gives the industry too much credit as any business works this way at some level –at least in a capitalistic society. On the other hand, an awareness of these forces (of the market) and how they work is crucial for doctors and patients (especially in this age of direct advertising) so that they can better navigate these sometimes muddy waters.

It needs to be made clear that market pressures drive the alternative medicine market in the same way –perhaps more so- as they do the pharmaceutical industry (sometimes they are one and the same!). In addition, the alternative industry (i.e.; supplements, homeopathic products, Chinese herbs) is not nearly as tightly regulated or policed as their “counterpart” is, making arguments against “big pharma” sound a bit hollow.

The science based medicine blog has a very interesting post “A foolish consistency” by Mark Crislip that discusses the undo influence of industry over the practices of medical doctors. As mentioned, topics like these need to be targeted and discussed openly and honestly. This is the best way to identify real problems and find solutions in a complex world.

By the way, veterinary medicine doesn’t seem -for the most part- to suffer near the pressure our counterparts in human medicine do. It seems easier to stand back and assess a particular drug or machine without some type of “market loyalty” ploy (i.e.; fancy gifts, free good or trips to wherever) getting in the way.

In the world of marketing and consumer “wooing” a saving grace, at least to some degree, with pharmaceutical companies is that they are tightly controlled and claims about their products need to be substantiated. Even with the biases often inherent in substantiating a product, it is still possible to evaluate them critically. That said there is still a question of whether pharmaceutical marketing is always a bad thing.

As noted by Crislip: “Does this marketing lead to worse outcomes? Or just more expensive treatment. I don’t have data. I will note that one of the driving forces of antibiotic resistance in bacteria is the overuse of broad spectrum antibiotics and choice of antibiotics is more often driven by marketing rather than science. Association or causality? ” This is definitely food for thought.

Crislip ends the post with the following quote: “In the interests of patients, physicians must reject the false friendship provided by reps. Physicians must rely on information on drugs from unconflicted sources, and seek friends among those who are not paid to be friends” http://medicine.plosjournals.org/perlserv?request=get-document&doi=10.1371/journal.pmed.0040150

At least one commentator, Dr RW gives doctors a bit more credit in their ability to discern the difference between market pressures and good medicine and find a balance between them.

He notes that “Many physicians I’ve discussed this issue with are aware that they are influenced by pharmaceutical company promotions. There is no reason to think there is massive self deception in the ranks of physicians. On the other hand many physicians would dispute any claim that industry promotions impact negatively on patient outcomes. As you acknowledged, there’s not a shred of evidence that they do. It is equally plausible that industry promotions (and their influence on doctors’ prescribing habits) are beneficial to patient outcomes…”

With respect to doctors applying evidence to practicing medicine as opposed to uncritically following “the market” there probably is some problem. However as Dr RW notes “I suspect many physicians do apply it (evidence). I certainly do. How? By being aware of the bias inherent in industry promotions. By applying appropriate analysis to the claims (e.g. looking not only at relative risk but also absolute risk) and by checking any such claims.”

It bears repeating that evaluating and studying issues like these dynamic market pressures which can impact social networks (doctors and patients) allows for a better understanding of real problems and opens the doors for meaningful improvements. These positive attributes; that of being self critical and self correcting, are part of what makes science based medicine –on balance- such an effective and successful practice as it thrives even in the buffeting winds of demanding special interests.

The power of social networking: medicine with meaning

Shredding a paper tiger

Carl Sagan once noted that pursuing the truth no matter where it took you is far more enriching and fulfilling than believing in fantasies and made up realities. No matter how harsh, if you acknowledge your limitations- your humanity- nothing trumps the search for truth.

This is a premise for many who chase down and expose false and deceptive lines of reasoning in human society in an unending search for those gems that shine true. This is why complementary and alternative medicine (CAM) sometimes sticks out like a sore thumb. It pretends to dress itself in a robe of legitimacy and reality claiming actual therapeutic abilities for many of the maladies of society. Yet most of its most basic tenets disintegrate like sand between your fingers if you stop to examine them closely.

Because CAM is so replete with falsehoods peeling away at the facade is an important exercise because it sheds light on what not to do as a client or doctor. In this way much of CAM can be seen for what it is; a non-falsifiable belief system. The doctors’ stethoscope gets replaced with a sorcerer’s wand, and the lab coat with a priests robe.

Critical thinking can also help clarify many problems and pitfalls of the relationship and bond between modern medicine and society. Though there are plenty of issues on the table here, a crucial point to remember is something Carl Sagan alluded to. We need to acknowledge our humanity as it is. In other words, no matter how close to the truth we might get, we are necessarily driven to live with some form of "human" meaning (i.e.; awe, spirituality, inspiration).

But what is it that breathes life and meaning into our everyday lives? This core question has been an insufferable bane to philosophers and the opium of the masses for innumerable religions. It’s likely it has no one real answer.

We have made tremendous inroads -in spite of our limitations- towards a better understanding of reality. At the same time though, certain human qualities such as esthetics, art, and “value” still belong to a hazy area within the spectrum of human society. Somewhere in this realm CAM has created its own meaning with powers it doesn’t have as it stakes claim to things it doesn’t own – namely human “bonds”.

Human qualities (i.e.; fear, anger, happiness, love) form an integral part of the human condition and who we are. Though they may be as hard to pin down as an electron orbit, they contribute to how humanity relates to the world as well as how one individual relates to another. What has all this discussion got to do with social networking?

The importance of interconnections

Richard Dawkins in “An Ancestors Tale” noted that -to some degree- evolution rhymes, patterns repeat themselves. From the gene to the cell and beyond, there is a thread of constant interplay occurring that allows for differing levels of connection. This can be observed throughout the interdependent ecological scheme of life on this planet.

Zoologically speaking, one of its most elaborate versions seems to come in the form of multicellular animals. Here the tightness of interaction (along with the need for a nervous system) seems to have produced a unique form of interconnection. This is a pattern that can be loosely followed from cells that make up organisms to organisms that make up larger groups, herds, to even human societies.

It seems that this repeating phenomenon of networking gives rise to many of the emergent qualities resulting from interconnectedness in humans. For example, phenomena such as consciousness, art and “morality” may be some of the hard to quantify byproducts of networking that are tied to clearer evolutionary mechanisms (i.e.; kin selection, altruism). That these qualities are hard to pin down doesn’t make them less important- especially when we try to understand what it is to be “human”.

The implications for gaining insight into the fuzzy realm of human interactions can have huge payoffs in medicine. For instance, much of what may be attributed to the placebo actually has to do with some of the spin off effects of social networking. This person to person interaction can have a significant influence on the quality of the human experience in medical interactions which can -in turn- positively impact health.

Much of the force and claimed power of CAM actually stems from these networking effects and not at all from the CAM method itself. If doctors better understand how these interactions occur and who they affect, perhaps many CAM modalities would atrophy and be thrown into histories trash bin- at least as medical therapies.

The always interesting Edge web site has a video of Dr Nicholas Christakis Professor of Medical Sociology at Harvard and Attending Physician at Mt. Auburn Hospital in Cambridge, Mass., discussing the remarkable properties of social networks, how they obey certain deep biological-like rules and the amazing capacity they have to spread many qualities including altruism, happiness, and even loneliness. These qualities seem to propagate in a way similar to “biological contagions” yet they are social aspects of human interactions.

This research takes the potential for social networks in medicine to new levels. According to his web site “This work takes seriously the contention that because people are inter-connected, their health is inter-connected. This work explores two aspects of social networks: the process by which they form ("connection") and the way they operate to influence behavior ("contagion"). Related work examines the health benefits of marriage and the consequences of spousal illness and widowhood. Other ongoing investigations consider the effects of neighborhoods on people's health, the biodemographic determinants of longevity, and the genetic bases for human behaviors. His past work has examined the accuracy and role of prognosis in medicine and ways of improving end-of-life care.”

Unlike the false magical claims of CAMs “humanity”, this research is based on solid research and science. If these properties are better understood, they could expand our ability to positively impact social networks. We inherently know that illness can indirectly impact others in addition to the ill individual -but we don’t know all the details and potentially miss out on an opportunity to effectively help a broader circle of affected people.

For example, Christakis evaluated how the illness of a spouse affected the healthy partner in the marriage and found that it is possible to identify individuals at greater risk for emotional stress and diseases of their own (mental health and substance abuse). This could allow for specific interventions depending on the circumstance that relieves the caregiver and minimizes the propagation of the negative social effects of what was originally a real organic medical disease in somebody else. This might seem like common sense, but studying its effects brings home the importance that medicine take social networks very seriously.

Part of what we understand as a “good bedside manner” has roots in being aware of these issues. By expanding our body of knowledge, it may be possible to formalize clear and effective approaches to the client/doctor relationship and teach aspiring students solid techniques that seam the “human condition” more intimately into the tapestry of medical practice. That way, these important social interactions would be less prone to false hopes and empty promises common in CAM while softening some of the “sharp edges” of modern medicine.

Christakis describes his research as follows “it is critical when you think of networks to think about their dynamics. A lot of times, people fail to understand networks because they focus on the statistics. They think about topology; they think about the architecture of the network. They think about how people are connected, which is of course incredibly important and not easy to understand either. While on the one hand the topology can be understood or seen as fixed or existing, on the other hand this topology is itself mutable and changing and intriguing, and the origin of this topology and its change is itself a difficult thing.

But here is something else: Once you have recognized that there is a topology, the next thing you must understand is that there can be a contagion as well — a kind of process of flow through the network. Things move through it, and this has a different set of scientific underpinnings altogether. Understanding how things flow through the network is a different challenge from understanding how networks form or evolve. It is the difference between the formation and the operation of the network, or the difference between its structure and its function. Or, if you see the network as a kind of super-organism, it is the difference between the anatomy and the physiology of the super-organism, of the network. You need to understand both. And they both interconnect and affect each other, just as in our bodies our anatomy and our physiology are interrelated.”

The implications of his work are somewhat reminiscent of the social “meme” concept that Dawkins originated and Blackmore is trying to legitimize. Whether these particular ideas reflect reality remains to be seen. The social networking scheme of Dr Christakis work though does appear promising. The potential benefits to understanding how social systems network and function in medicine can positively impact health on a broader more human scale (without CAM help). This is a good thing.

Vaccinations and “herd immunity”

Cooperating to save lives

One of the more interesting phenomena in the realm of epidemiology is how infectious disease affects large populations. Though the patterns of morbidity and mortality will fluctuate, taken as a whole they tend to adversely impact certain subpopulations more than others. For example, the very young and very old can have higher rates of illness and death from many infectious disease.

The obvious benefit of vaccinating against certain diseases in all types of animals has been nothing less than spectacular and revolutionary. From human Small Pox to Canine Rabies, the resulting eradication or reduction of disease exemplifies the power it has had to positively impact health- especially in many of the most susceptible groups. In addition to the obvious effects of protecting an individual from a disease, vaccinating whole populations has another powerful effect.

By preventing the spread of infection, vaccination can reduce and sometimes eliminate the risk of disease transmission in general -otherwise known as herd immunity. Dr Panagiotopolulos of the Institute of Child Health in Athens (Egypt) defines herd immunity as “The indirect protection from infection of susceptible members of a population, and the protection as a whole, which is brought about by the presence of immune individuals.” This means that, for example, in addition to having the ability to protect individuals from a certain disease, vaccinating a population incurs another level of protection -like an umbrella- and blunts the propagation of the disease. Many people are vaguely aware of this property, but don’t realize just how crucial it is in any cases for providing optimal protection.

This phenomenon can be described mathematically and provides the theoretical foundation for many of the herd immunity effects observed in real vaccination programs. An infection will usually spread via the “mass action principle” and is a function of the number of susceptible individuals. The equation is described as follows:

C_t+1/C_t = f (S_t), where C is the number of infected cases, S the number of susceptibles, t a given time period, t+1 the next time period. (This can also be expressed as: C_t+1 = S_t C_t r, where r is a transmission parameter¹).

What is so interesting about this equation is that it can help describe the dynamics of how infections spread throughout populations. Dr. Panagiotopulos notes “ It was introduced in the 1900’s and helped understand the dynamics of epidemics of diseases like measles: as the infection spreads during an epidemic, the number of infected cases in each successive time period initially increases while the number of susceptibles in the population decreases; therefore, there will be a point when susceptibles become sparse and the number of new cases in each successive time period decreases; and, finally, susceptibles are so scarce that there is no more than one new case for each case in the previous time period, and the epidemic fades out although a number of susceptibles have not been infected.”

Several potential effects can be gleaned from the movement of diseases through these populations and are usually related to the beneficial effects of vaccination. In general, the propagation of diseases are either blunted or even stopped, especially if a large part of the population is protected (herd immunity). However, there can be adverse effects (“perverse effects”) in some cases and these are dependent on the specific disease in question and the level of protected vaccinates.

For example Rinderpest in Africian cattle, Chicken Pox and Rubella in humans have peculiar characteristics that require special consideration. Rinderpest vaccination can be more targeted to focal outbreaks due to a synergistic herd immunity that makes immunizing the hold population less beneficial. Rubella, if vaccination campaigns are less than ideal, has the unfortunate characteristic of protecting one group while actually placing another at higher risk than before.

In these cases, it is vital that other factors are taken into account before implementing broader vaccination campaigns. Of course, this is a point that anti-vaccination advocates get spectacularly wrong as they misrepresent this particular form of herd immunity (i.e.; claiming that all vaccines do this, or taking it out of context) and use this false knowledge to decry vaccinations in general.

One of the most important points to consider is that vaccination protocols need to cover a high percentage of populations to reduce complications in disease dynamics –especially in these special instances- to optimize the herd effect. In other words, a significant number of unvaccinates can put a larger population at risk². In the cases where it really matters, the selfishness of anti-vaccine advocates can directly cause harm to others.

The bottom line is that herd immunity is an extremely potent natural phenomenon that provides effective protection –sometimes even the eradication- of many diseases. The implementation of vaccination campaigns need to be realized with care and preparations made so that the threshold of proper herd immunization levels can be reached. Vaccines protocols can be modified as other factors might present themselves (synergistic immunity as in the Rinderpest case).

With people, the best results seem to come with cooperative efforts (there may be -though a very touchy subject- a place for obligatory vaccines in some cases). Depending on the country, different educational and culturally sensitive strategies may improve the initial conditions for starting vaccination programs. Perhaps similar strategies may appease some in the anti-vaccine crowd in the US, though many in this group seem heavily biased against science and reason- at least when it comes to vaccines.

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(1) Dr. Panagiotopulos adds "The latter expression explains the name of the "mass action principle", which was given by analogy to the "law of mass action" in chemistry, according to which the velocity of a chemical reaction is a function of the concentrations of the initial reagents."

(2) Those small number of individuals who can not be vaccinated for whatever reason (i.e.; illness, immune compromise) would be theoretically protected indirectly through the herd effect but this is not meant for other wise healthy groups that refuse vaccinations (i.e.; for cultural or belief related reasons) and this can be a big obstacle.

Cats, toxoplasma and shizophrenia

On biological complexity

A recent article in the February publication of DVM news magazine (a veterinary multimedia news source) discusses a study that linked a cat parasite; toxoplasma gondii, to the risk of schizophrenia in humans (affects about two million individuals a year or 1% of the US population).

This story is interesting because it illustrates just how interrelated and messy the world of life can be. It also exemplifies just how deeply a parasitic organism can penetrate into a larger ecosystem. By utilizing differing mechanisms to weave a tangled web toxoplasma gondii has become so enmeshed with warm-blooded animals and their environment that it would be extremely difficult or next to impossible to eradicate- and you thought politicians were bad!

The study the article refers to is discussed in the American Journal of Psychiatry and is titled “Selected infectious agents and risk of schizophrenia among US military personnel.” It forms part of an increasing number of studies that seem to be finding a possible association between people exposed to toxoplasma gondii (based on collected serum samples) and an increased risk for developing schizophrenia.

This particular study stands out in that it is larger than most, serum samples were collected in many cases before a diagnosis of schizophrenia was given and the subjects (military personnel) could be clearly compared with non-schizophrenic subjects from the same population. Though the link was small and there are some important confounding factors, combined with other studies these results shed some light on one possible infectious trigger to schizophrenia in predisposed (genetically?) individuals.

Notes on T gondii

Toxoplasma gondii is a well known ubiquitous intracellular parasite that has a rather complex and fascinating life cycle involving a variety of intermediary hosts (i.e.; pigs, goats, insects, humans, and chickens) as well as the environment (i.e.; water and soil). Felines are definitive hosts, which mean this is where toxoplasma will eventually sexually reproduce and form the oocysts that can infect other organisms on a journey that eventually takes some back to infect other cats.

In humans the CDC notes that it is known as one of the most common human infections in the world affecting over 500 million people. In the US it is the third leading cause of death related to food borne illness. Though about 60 million people in the US carry the parasite, most healthy individuals have no symptoms although pregnant women and imuno-compromised people are at higher risk for problems.

Infected cats usually shed oocysts soon after weaning and only for a short time. Though oocysts shed from infected cats spread the illness, the most common form of exposure in humans is through the ingestion of raw or undercooked meat (usually pork, goat, and lamb). Interestingly, there is no correlation between increased toxoplasmosis and cat ownership (there are a couple of studies that seem to relate adult schizophrenia and childhood exposure to cats in the household- not enough epidemiological power to make anything out though).

Because this organism is so common and the infection to humans is usually between intermediaries and not cats, it turns out that simple hygienic measures do the most to minimize problems. Feeding cats cooked food, cleaning there litters every day, reducing stray populations are some effective measures to reduce infection and environmental contamination. In humans eating cooked meats (and pasteurizing goats milk), cleaning ones hands after outdoor activities such as gardening, covering children’s sandboxes and controlling insect mechanical vectors (i.e.; houseflies, cockroaches). It should be noted that the biggest risk of oocysts exposure is in warm, moist, or tropical climates and lower in arid and frigid areas of the world.

The bigger picture

The January 2008 American Journal of Psychiatry editorial Alan Brown MD, MPH suggests that the idea parasitic infections can play some role in psychological diseases is not as strange as it sounds and does have parallels with other infectious disease processes.

Dr Brown notes that “Authorities from several diverse disciplines, including infectious disease, neonatlogy, pediatrics, neurology, and obstetrics and gynecology have long known that infections during prenatal and postnatal life have many neuropsychiatric sequelae, including behavioral problems, mental retardation, learning disabilities, and mood alterations.”

Improved data bases are allowing for more refined statistical analysis and seem to be finding associations between “prenatal exposure to influenza, toxoplasma gondii, genital/reproductive pathogens, and immunologic disturbances with an increased risk of schizophrenia.” Though still in its infancy, there are animal model studies that also support a link between behavioral anomalies consistent with what is seen in schizophrenia and “anti-viral like” inflammatory responses. So, the association with infectious disease and schizophrenia, if it exists, is not due just to a feline linked parasite.

If the body of evidence eventually indicates that infections do in fact impact schizophrenia in some cases then preventative measures as well as different treatment approaches could be used to reduce this mental illness in some people. Dr. Brown notes that “several infections that have been associated with this disorder can be effectively treated with antibiotics and prevented by vaccination and by minimizing the occurrence of risk factors for these infections.” That is the good news.

This is only a small part of the picture as further epidemiological, molecular genetics, genomics, brain imaging and human developmental (looking for precursors) studies expand researchers’ ability to discover new factors involved with schizophrenia risk as well as enhance their search for new treatments.

Though informative, these findings could easily be misconstrued by many who don’t have a biological background as an indictment against our beloved pet cats. It doesn’t emphasize that though toxoplasma has “chosen” felines as its definitive host where it reproduces sexually and sheds its oocysts, it is in fact an organism that takes advantage of many other animals and environmental factors –as intermediary hosts- in an elaborate “macro- bio-ecological” parasitic relationship.

These overlapping characteristics are the M.O. of innumerable organisms from viruses to larger organisms and illustrate how some of them don’t work under our taxonomic classifications- species are more blended from their viewpoint. Therefore it behooves people to take the bigger picture into account, use common sense –to have a “situational” awareness of the world around us- and most important remember that cats still rule!

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Ref:

Greene E Craig. Infectious disease of the dog and cat (3^rd edition). WB Saunders. Philadelphia, Pennsylvania. 2007

Niebuhr, D.W., Millikan, A.M., Cowan, D.N., Yolken, R., Li, Y., Weber, N.S. (2007). Selected Infectious Agents and Risk of Schizophrenia Among U.S. Military Personnel. American Journal of Psychiatry, 165(1), 99-106. DOI: 10.1176/appi.ajp.2007.06081254

Transforming Data

glimpes of evolution in the information age

Hans Rosling is founder and director of Gapminder, an interesting non-profit venture that promotes sustainable global development. He has breathed life into the world of numbers and managed to do what many thought impossible.

By developing a software program named Trendalyser he was able to “unveil the beauty of statistical time series by converting boring numbers into enjoyable, animated and interactive graphics.” The ultimate goal is to access all of the existing and accumulating informational data bases of the world – which are critically important yet often stored in archaic and difficult to reach places- and transform them into large interactive pools of information that display in incredibly useful formats.

The ability to get more out of the data is truly astounding and has global implications in developmental, economic, health, environmental and social sectors just to name a few. An example of what this technology offers can be seen in Roslings 2006 discussion “debunking the myths of the world.”

The potential for evaluating, examining, and understanding statistical information is staggering. In this way, better decisions and more effective solutions could be implemented. For example, trends in medicine could be tracked and correlations made that favor optimal health thereby improving our understanding of what does and doesn’t work.

These trends could be noticed quicker and targeted more precisely with much more nuance (i.e.; what subpopulations respond to what therapies). This could have a significant impact in science and evidenced based medicine in the near future and promises to make life easier for practitioners striving for the best medicine.

On a related note, there is a bourgeoning new generation of web based services in human medicine that promises to revolutionize how medicine is practiced. The ScienceRoll site has an excellent review of the possibilities.

Should Complementary and Alternative (aka Integrative) Veterinary Medicine be taught in vet schools?

The short answer is NO.

The core of today’s veterinary education has, for good reason, been built upon a vast web of interconnected and established science. With this in mind, the belief in the need to teach Complementary and Alternative Veterinary Medicine (CAVM) at veterinary schools immediately brings to the fore a looming dilemma.

Science is a powerful filter and provides a foundation from where medicine has discovered truly effective therapies. It has proven an excellent tool for excising the useful from the useless (i.e.; statistical significance vs. fanciful testimony and tenuous beliefs). To date, science is the only way to assure that medicine stays on the straight and narrow and optimizes its effectiveness. Without it, no matter how well intentioned, the practice of medicine falls prey to a world of delusion and fairy tales.

Medicine develops and refines innumerable modalities and therapies based on accumulating evidence. Though this evidence may vary in robustness and quality it is always grounded in science. In general, you can’t skip over this basic filter and practice any kind of “medicine” that suits your fancy- that usually leads to the realms of metaphysics and belief.

The machinery for seeking and establishing effectiveness in medicine assumes the plausibility of what is being studied. If it is not a plausible modality the best the research can offer is often just garbled noise -equivocal statistical data- that is neither here nor there. This is something novice students are not being taught and herein lays the problem.

Medical education needs to emphasize critical thinking tools and teach aspiring doctors how to navigate within the depth of established science based medicine before tackling fringe areas such as alternative medicine.

If a student sees a CAVM modality as part of the curriculum of veterinary education the assumption is made –whether these young minds know it or not- that there must be something to this particular practice. It falls under the rubric of an accepted standard of practice and therefore is a part of general practice. This simply is not the case because if it were there would be no “alternative” in alternative medicine.

When it is implicit to students that academia tolerates alternative medicine as “just another way” you compromise these students science based education. Dr. Colquhoun points out that “Once any treatment is shown beyond doubt to be effective, it ceases to be ‘alternative’ and becomes just like any other part of medical knowledge. That means that ‘alternative medicine’ must consist of unproven treatments.” It is not the domain of academia to be teaching unproven treatments to young students.

Introducing unsubstatntiated non science based modalities and therapies that might have some plausible basis (acupuncture), no matter how scientific they might appear, to these aspiring professionals before they are ready to critically evaluate them is a bad idea. It opens the doors to a Pandora’s Box as other alternative medical paradigms (i.e.; homeopathy, energy medicine) will inevitably also demand a place in academia.

This is reminiscent of “teaching the controversy” of evolution that intelligent design advocates support so vehemently. This red herring demonstrates an alarming lack of actual scientific knowledge regarding proper methodology and smacks of dogma and pseudoscience.

Dr. Colquhoun points out an interesting observation with respect to the curious confounding of pseudoscience and science ("quackademics") in medical schools. He states that “All these outfits have two things in common. They all claim to be scientific and evidence- based, and none has produced any real evidence that any of their treatments work.”

This is one of the weaknesses to claiming that the CAVM offered in veterinary schools is being scrutinized under the framework of science. If they were, they would be pulled out of the cirriculum or possibly relegated to research. As noted though, you can't use evidence-based research very well when the underlying science is suspect.

In addition, the fact that CAVM has become a fairly popular practice among some people and practitioners outside academia is not an excuse to teach it in school. This is an appeal to popularity and gets medicine no-where.

It has been noted that veterinarians need to be more non-judgmental and not stigmatize CAVM; implying a rush to judgment and a bias against CAVM. In some cases, the implication goes; this may threaten a client/doctor relationship and could lead to the loss of clients who might move entirely to alternative medicine. Medicine needs to “adapt to changes brought about by societal influence” and the popularity of CAVM –another effective way of doing medicine- needs to be accepted, embraced, and taught in school. This is threading misrepresentation with populism- a dangerous mix.

Fallacious reasoning like this creates false realities and gives little credence to the ability of a skilled practitioner and the influence they can have on client/doctor relationships. The opportunity to communicate and teach science based medicine is taken seriously my many practitioners.

They feel obligated to create a comforting, supportive, and trusting bond that openly and honestly approaches the situation at hand. Practicing the best science and evidence based medicine they can goes hand in glove with this bond and most clients will respect that.¹

Though, there may be emotionally charged biases against CAVM at times, the fact remains that -for the most part- it is not science and it is definitely not a substantiated medical modality. Disregarding or not recommending CAVM if it does not fulfill the requirements of science and evidence based medicine is not being biased.

Learning how to communicate and interact empathetically with people is by far one of the most important skills a veterinary student can learn. This is what should be stressed more in university curriculums than teaching pseudo-science. On the other hand, future practitioners need the critical thinking tools and knowledge to clearly and dispassionately discuss why a given CAVM modality may not be the most ideal approach to a given problem. This can be done without creating the impression that CAVM is or should be an accepted part of scientific medicine.

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1. If a client elects to proceed with a CAVM modality then it’s their decision, and though sometimes difficult, practitioners should strive to continue working with these clients if possible and promote what is in the animal’s best interests.

Pet Foods: notes from the experts

Towards a greater understanding (part 3)

The idea of government oversight has always been a bit of a touchy subject in the United States; a country known for an independent citizenry strong on "freedom of choice". This admirable quality though can sometimes create a lot of tension. The struggle to balance between allowing an indiscriminate free flow of goods and the need to protect the public has been the source of many regulatory headaches. Depending on the subject in question, there are varying degrees of expected government intervention the public expects.

For example, entertainment is one thing and medical care another. The intensity of control between the two is very different. Since the early nineteenth century society decided to filter a haphazard and dangerous quackery filled world of medicine through the tried and proven framework of science. Those practices that couldn’t pass muster (i.e.; homeopathy and bloodletting) fell out of favor or were disregarded. Though, unfortunately today there is a resurgence of non-science in medicine, this framework has worked extremely well in disseminating effective medicine to many more people than would otherwise have been possible.

This basic concept (though not nearly as tight as in medicine) is also utilized in the oversight of food safety for animals in the United States, but the current regulatory system is probably not what most people imagine.

Last years pet food recall illustrates some of the strengths and weaknesses of the US regulatory and inspection system for pet food ingredients. Laflamme notes that “There are issues at all levels: USDA issues in terms of guidelines and inspections, import issues, domestic issues, and, of course, pet food companies have their own standards for determining the nutritional value of the ingredients and tests for known contaminants...What happened in the 2007 recall was deliberate contamination of an ingredient from something that we wouldn’t even think to look for. There’s little that can be done if somebody wants to deliberately put toxins into a food, whether it’s for humans or pets.”

In other words, the current regulatory model was not looking for what McChensey described as a “strictly economic adulteration of a product.” He adds “The other thing is that pet food and animal feed are regulated under the adulteration provision of the Food, Drug, and Cosmetic Act. So, the presumption is that a company will make a product that is not adulterated or unsafe.” Though most companies will operate under these constraints there are no set regulations that require them to follow quality practices for “non-medicated feeds” which comprises almost all of the pet foods. So if there is a problem its “difficult to take action against someone because of a problem.”

On the other hand, regulatory agencies and regulations have a two pronged strategy. They are there not only to protect the consumer but as Roudebush notes “are there to protect the companies too.” He states that industry plays a critical role in helping to set up standards that protect them as well as the public. He uses the aircraft industry as an example; “every 5 years, a group that represents industry- airplane manufacturers, the government, academics- comes up with standards for lubricants that are used on commercial and private aircraft. Industry is important. Companies have the technological know-how and share that information, allowing industry as a whole to come up with the regulations that protect the users and also the companies.”

On a related note it is important to realize that neither the AAFCO nor the Pet Food Institute are regulatory bodies nor have they been created by the pet food industry. The AAFCO for example, is composed of regulatory people from all 50 states that among other things facilitate interstate commerce. Though they may contribute opinions about regulations they don’t have the ability to establish regulations.

The USDA is charged with regulating many food related products. For example, they have a person assigned to all slaughter plants that are making a USDA-regulated product. On the other hand, it’s the FDA- under the Food, Drug, and Cosmetic Act- that is ultimately charged with the oversight of the safety of imported ingredients into the US. McChensey notes that “The FDA does look at about 1% of the products crossing the borders...ultimately it falls to the company to make a safe product.”

Daritotle adds that “Most of the major pet food companies have been fairly vocal about the quality control in place and have quality-assurance programs accordingly.” And as Roudebush states “the reality is that most of us think if the company is reputable, then it is assumed that quality-control procedures are in place.” For the most part, this is true and a part of the combined effort it takes to produce a generally safe product.

But there are still plenty of holes and inefficiencies, especially in this era of increasing globalization, and it behooves the veterinarian and pet owners to be vigilant. Having a better idea of how things are set up helps us to perhaps find other more constructive solutions.

As we struggle to balance a full plate of sometimes contradicting issues (i.e.; the need to protect ourselves vs cost of that protection, freedom of choice vs limiting that freedom to choosing among safe products, cheaper vs expensive food ingredients) it all comes down to being well informed and finding ways to cooperate together.

Taken as a whole, cats and dogs in this country have the opportunity to be healthier and live longer than ever before. By working as a team, pet owners, veterinarians and others can successfully navigate these challenges and come up with excellent nutritional solutions for our beloved pets.

Cectic- The Comic

Pet Foods: notes from the experts

Towards a greater understanding (part 2)

There are many variables that go into making informed decisions regarding what to feed a healthy dog or cat. Having a solid veterinary/ client relationship forms the foundation from where information can be sifted taking into account each pets unique circumstance in order to come up with a reasonable dietary plan.

Among the most important issues with respect to pet food is that we have to make dietary choices based on the best science and evidence available and avoid the allure of unsubstantiated claims. The big challenge here is that things aren't always clear cut. For example dog food companies, whole food advocates, and purported alternative nutritionists all -in one form or another- fall under the sway of faddism, premature nutrient recomendations, consumer driven demands, and market pressures.

The more informed we are the better. If our information is balanced, dispassionate and accurate then picking a path through this quagmire is easier. With that in mind, we can go back to the Veterinary Forum nutritional expert panel for more interesting discussion regarding pet food and the state of the industry.

On ingredients

This appears to be one of the most pressing issues when it comes to some of the common general misunderstandings. Part of the problem stems from a general lack of basic skills in science and general nutrition which can impede a more nuanced perpective of this complex issue.

At least some of the details regarding food ingredients, preservatives, additives, and other constituents need to be understood enough so that prudent choices can be made by veterinarians and pet owners. For example, a pet food company might cut corners too much, or someone may claim a certain chemical additive is just poison. Armed with the right tools, a person could effectively analyze the issue at hand and make a rational more balanced determination of the problem or claim and what to do about it.

One of the interesting points mentioned in the discussion was that people in general seem to lose sight of the fact in spite of the huge number of available foods products on the market, animal needs have not changed too dramatically. Delaney notes “the nutritional needs of dogs and cats really haven’t changed. Yet, so many new products are being introduced. Veterinarians need to start by understanding the nutritional needs of dogs and cats and the individual factors that affect those needs.”

A rough analogy is that a shirt and jeans are always the basic and essential part of a teen’s attire. You can dress it up, loosen the pants, change the colors, add jewelry, or add whatever puffery the teen demands; but in the end the jean and t-shirt never goes away.

A detailed discussion of all the common components of food such as micro and macronutrients is beyond the scope if this post. However, we will touch on one topic mentioned by the experts on the panel as an example of some of the issues involved with food sources and pet food ingredients.

There is a lot of misunderstanding regarding the meaning of macronutrients in pet food. These are the main components of a diet and comprise the bulk of for example proteins, fats, and carbohydrates. Freeman notes “There’s so much misinformation about ingredients on the list. For example, lamb listed as the first ingredients is sometimes perceived as better than a by-product, which has become a frightening term to some people. Yet, some labeling might list the first ingredients as beef heart, beef liver, or beef lung without the word by-product.” This belies a very basic problem with the attitude and general perception of what an acceptable macronutrient might be. Daristole adds that “Consumers may not understand that most of the macro-ingredients in commercial pet foods are indeed by-products of the human food industry, not because they are bad for anyone but because of food preferences.”

If one stands back and thinks for a moment, it becomes evident that these are big issues and could be barriers towards comprehending nutrition at the most basic levels. Roudebush very eloquently reminds the panel that “My grandfather and father grew up on farms, and when an animal was slaughtered, all of it was used. There were no by-products. We have gotten away from that practice. People who are entering veterinary medicine today have less of that background. Then, so much of it is cultural in the United States, where people are less accustomed to having contact with where our food comes from and how it is used.” This is not really a yearning call for days of old. It is an important observation that requires our attention as we try to navigate through the issues of pet food ingredients.

On the other hand, a promising and positive development has been the increasing consumer awareness of “greener” and more wholesome (organic) food ingredients as well as concern for how our food sources are handled and treated. This opens the doors to perhaps a more balanced approach to a host of agricultural practices and animal husbandry techniques.

Roudebush states that “The AAFCO manual defines organic as a formula feed or a specific ingredient within a formula feed that has been produced and handled in compliance with the requirements of the USDA natural organic program.”

The problem seems to be, that due in part to a “disconnected” consumer, terms and descriptions like “organic”, “nature”, and “human grade”(1) that supposedly denote some type of superiority either in production methods or nutritive value over “conventional” methods turn out to be more semantics than anything real.

In other words, we shouldn’t throw the baby out with the bath water when it comes to evaluating the pet (or human) food industry. Though a laudable ideal, the organic industry has its own “foot print” to contend with. The book “An Omnivores Dilemma” is a good introduction to the realm of food production and the challenges of feeding the masses well while balancing food gathering and distribution.

Raw, commercial, and homemade pet food

In and of itself, the concept of raw food diets is simply another way of delivering food to pets. The problem is when people claim that it is a superior method for feeding dogs and cats. Though still a fairly rare practice in the US (more common in Australia) it is on the rise and there are several companies that distribute different types of commercial raw food mixes.

According to Freeman “ there are no proven benefits linked to raw diets, yet there are multiple studies showing nutritional imbalances, both in commercial and homemade raw diets, and multiple studies showing contamination in the vast majority of raw diets. There is a risk for the people in the household but also for the pets themselves. So, in terms of raw-food diets the risks far outweigh any potential benefits.”

Freeman, Curchill, Laflamme and Tefend note that there are more reports of nutritional deficiencies and excesses with raw and homemade diets than with many commercial diets. Roudebush notes that no AAFCO maintenance feeding trials have been done on any homemade prepared diets and this is a problem when looking for evidence.

Laflamme mentioned that there have been two independent studies that “compared dogs fed commercial pet food with dogs fed homemade diets. The study (1999) I’m most familiar with involved 1,000 dogs in three different groups…There were significant differences in terms of health problems being greatly reduced by the feeding of commercial pet foods.”(2)

On the other hand, this is not to say that home made foods in general don’t have a place “on the table” and indeed can often be a critical part of the nutritional puzzle for some pets and for any owner willing to put in the effort needed to do it right.

However, they need to be complete and balanced and Churchill cautions that “I frequently see well meaning owners make substitutions to the recipe, until over time, ‘diet drift’ occurs, and the diet may no longer resemble the original formulation.”

McChesney and Churchill also add that salmonella risk is higher when dealing with the day in/ day out processing of homemade and especially raw diets and extra care needs to be given for maintaining routine hygienic standards. Cooking homemade food does not significantly diminish its dietary quality (problems with heat labile substances can be corrected) and reduces the risk of food borne disease.

Again, it is more advantageous to take note of the evidence, science, and -to a degree- the opinions of experts in the field. No, it’s not perfect and problems abound, but the ability to make the best decisions regarding what to feed our pets lies here and not on assumption, hearsay, what we’d like to believe.

(Part 3 touches very briefly on the recall and regulatory issues)

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1) Roudebush notes “According to AAFCO the term human grade cannot be used anymore. However the term continues to be used on websites, in brochures and on some labeling.”

2) Interestingly, there is an often repeated study alternative veterinary nutritionists fondly allude to that claims to support raw foods or the broad use of nutritional supplements. It is an old 1940’s report known as “Pottingers cats” that seemed to evidence multi-generational deficiencies in cats with cooked or “processed” foods. The more likely reality was that the affected cats suffered from other confounding issues such as a species specific sensitivity to taurine deficiency, a heat labile protein, that when added to a cooked diet corrects this problem.