The Chicago Tribune, “chronic Lyme disease,” and demands for false balance

During the six years of its existence, one frequent complaint I’ve had on this blog, it’s been about how the press covers various health issues. In particular, it’s depressing to see how often dubious and even outright false health claims, such as the claim that vaccines cause autism, that cell phones or powerlines cause cancer, or that various questionable or even quack remedies work for various diseases are reported credulously. Often this takes the form of a journalistic convention that is more appropriate for politics and other issues but not so appropriate for scientific and medical issues, namely telling both sides as though they have equal or similar weight. While this is fine for politics, it’s not so great for discussing, for instance, the scientifically discredited notion that vaccines somehow cause autism. Yet, in such stories, almost invariably there is an anti-vaccine crank like Barbara Loe Fisher, Jenny McCarthy or someone else from Generation Rescue, or someone like Sallie Bernard from SafeMinds cited as though she were on equal footing, scientifically speaking, with scientists who have dedicated their lives to the science of vaccines. Sometimes, the story takes the form of a credulous acceptance of pseudoscientific claims, with a token scientist or skeptic tacked on at the end to give a small quote for “balance.”

One exception to this profoundly annoying pattern (if you’re a skeptic) has been the journalism of Trine Tsouderos, who with Pat Callahan, has produced over the last year or two a number of excellent, science-based stories on the anti-vaccine and its associated “autism biomed” movements, including an expose of Boyd Haley’s “rebranding” of an industrial chelator as an autism treatment. She’s even taken on “America’s doctor,” Dr. Oz. As a result, she’s been demonized by cranks, up to and including having her face crudely Photoshopped into a picture of a Thanksgiving feast in which she and various others whom the merry band of anti-vaccine loons at Age of Autism view as enemies were portrayed as sitting down to a meal of dead baby.

Most recently, Callahan and Tsouderos published an article about the dubious diagnosis that is chronic Lyme disease entitled, appropriately enough, Chronic Lyme disease: A dubious diagnosis, which was subtitled, also quite appropriately, “There’s little good evidence that chronic Lyme disease exists. Yet doctors are treating it with drugs that put patients and the public at risk.” And so there is, and so all too many dubious doctors do. Because this article speaks for itself and is nearly two weeks old, which in blog time is akin to being two years old, I’m not going to discuss it in detail. I will say that it is quite good and lays out the issues better than I’ve ever seen them discussed in a mainstream newspaper or magazine. I’ll also point out that chronic Lyme disease has become such a cause célèbre that in Connecticut the legislature passed a law to protect Lyme quacks from being disciplined by the state medical board for using long term antibiotics to treat chronic Lyme disease. In essence, as Steve Novella pointed out at the time, they carved out an exception to the standard of care and told doctors in Connecticut that they don’t have to worry for not meeting it.

Don’t get me wrong. Lyme disease is real. There does even appear to be a post-Lyme disease syndrome, which is seen in patients who had Lyme disease and now have chronic symptoms (such as fatigue, various pains, and difficulty concentrating) after having been treated. Indeed, this is even referred to as category 4 Lyme disease. What causes this syndrome is a mystery, and there is no doubt that there are patients out there with debilitating symptoms after being treated for Lyme disease, but current scientific and clinical evidence does not support the idea that these symptoms are due to a chronic ongoing infection or that prolonged courses of antibiotics do any good. Steve Novella has written a good treatment of the issues involved (here and here), as have Mark Crislip and Peter Lipson.

As good as Callahan and Tsouderos’ article was, it’s not surprising that it resulted in criticism. One criticism actually appeared in the Knight Science Journalism Tracker’s blog in the form of post written by Paul Raeburn, former senior editor for science at Business Week, former science editor at the Associated Press, author of three science books, and director of a university science journalism program, entitled Chicago Tribune off balance on chronic Lyme disease. For the most part, it’s an article complaining about the journalism of the article. Boiled down to its essence, Raeburn’s complaint is the opposite of what we skeptics, scientists, and supporters of science-based medicine complain about all the time about journalists, namely that Callahan and Tsouderos did not fall into the trap of false balance, did not give undue credence to pseudoscience, and did not “tell both sides” as though they had equal or roughly equal credence. Indeed, Raeburn says just that much in the very last paragraph of the article:

In short, what Callahan and Tsouderos have done is to argue that chronic Lyme disease can’t exist because the people who say it does are nuts.

A far better approach would have been to report the evidence, pro and con, and to quote the most persuasive advocates for and against chronic Lyme disease-not the least persuasive. And to give both sides equal time to speak.

The first sentence, of course, is a massive straw man argument. That is not what Callahan and Tsouderos were doing at all. Seriously. I reread the entire Tribune Lyme article, and nowhere did they say or imply that believers in chronic Lyme disease are nuts. Of course, this is a frequent complaint that people who have been victimized by quackery use: That critics of quackery are calling them crazy. This sort of retort is common whenever it is pointed out that conditions that could well have a strong psychological overlay do, in fact, have a strong psychological overlay; those suffering from it will cry that you’re calling them crazy. Remember when I discussed Morgellon’s disease? Same thing. It’s an easy attack, a veritable cheap shot, though. Yes, sometimes it’s true, but far more often in my experience it’s a cheap shot.

As for the last paragraph, I can’t find a better distillation of the “tell both sides” mantra. Again, in the case of a genuine scientific controversy, this is not an unreasonable approach. However, it is not controversial in medicine that chronic Lyme disease is almost certainly not a result of actual chronic infection and that long term antibiotics don’t do any good and can cause harm.

Raeburn also has a bit of difficulty in defining what does and does not constitute a legitimate medical authority:

Again and again, Callahan and Tsouderos give far more space to advocates making questionable claims than they do to experts who refute those claims, allowing the serious case for chronic Lyme disease, whatever that might be, to be buried under the dubious claims of advocates.

The reporters go on and on impuguning patients and advocates without ever telling us whether there is a debate among legitimate experts about whether Lyme disease might assume a chronic form.

Could it be, perhaps, because there aren’t really any legitimate scientific experts who support the idea that long term chronic antibiotics are useful for the entity that is chronic Lyme disease? Could it be because randomized clinical trials have been done and don’t support the efficacy of long term antibiotics to treat category 4 Lyme disease? Indeed, after pointing out that the nation’s largest organization for specialists in infectious disease concluded that there is “no convincing biological evidence” for a Lyme infection that persists after treatment and continues to sicken and that three panels of experts from the Infectious Diseases Society of America and one panel from the American Academy of Neurology came to the same conclusion, namely that the diagnosis of chronic Lyme disease is suspect at best and that treatment with long term antibiotics is ineffective and risky, Callahan and Tsouderos write:

The evidence against the effectiveness of long-term antibiotic therapy is especially strong — supported by four randomized, double-blind, placebo-controlled clinical trials.

Patients in three trials receiving long-term antibiotic therapy did not do significantly better than those receiving placebos. In one other trial, patients receiving antibiotics felt significantly less fatigued than those receiving the sham treatment, though many of the antibiotic patients figured out they were receiving medicine, a grave flaw in the study.

They also point out:

However, the clinical trials on long-term antibiotic therapy found it can cause serious, even life-threatening problems. In one study, one-fourth of the patients suffered severe problems linked to the treatment, including blood clots, infection and the loss of a gallbladder.

I call B.S. on Raeburn. For a news article written for a mainstream newspaper, this is a very good discussion of the evidence against long term antibiotics for chronic Lyme disease. I mean, jumpin’ Jesus on a pogo stick! They even pointed out that one of the trials had problems with its blinding. What does Raeburn expect? A listing of the randomized, double-blind, placebo-controlled trials, the numbers of patients, the experimental designs, and the statistical analysis? Raeburn was also quite disingenuous in the way he framed this quote:

They then quote chronic Lyme advocates at length before introducing another expert, Dr. Paul Lantos of Duke University, whose quote, in its entirety, is: “Why take needless risks with people’s lives?”

Go back and look at Callahan and Tsouderos’ article, and you’ll note that this quote by Dr. Lantos directly follows the paragraph I cited above about the complications of long term antibiotics observed in clinical trials up to and including the loss of a gallbladder. In context, Dr. Lantos’ quote made perfect sense, particularly given how Callahan and Tsouderos follow that quote by pointing out an example, namely a 52-year-old patient in Minnesota who developed drug-resistant bacteria after 10 weeks of antibiotic treatment for a diagnosis of chronic Lyme disease.

Of course, the problem is that what Lyme advocates have for evidence is the same type of evidence that “autism biomed” advocates have for their woo: Anecdotes and testimonials. The blog Relative Risk describes this quite well as “a strange collection of aging, irrelevant works,” consisting largely of case reports (i.e., anecdotes). And that’s what Callahan and Tsouderos present, anecdotes and testimonials of Lyme advocates. The further problem is that Raeburn recognizes that this is a vastly inferior form of evidence but doesn’t recognize that that’s all Lyme advocates have. Particularly galling to Raeburn appears to be the passages in which Callahan and Tsouderos describe the illegal activities of many doctors pushing the idea of chronic Lyme disease against the standard of care, several of whom have faced legal difficulties. Raeburn appears to be particularly irritated by the singling out of Robert Bradford, founder of the Robert Bradford Research Institute in California, who was quoted as calling Lyme the “potential plague of the 21st century” and likening it to the Black Death, all while making the claim that Lyme disease might be a “contributing factor in as many as half of all cases of chronic illness.” Callahan and Tsouderos pointed out that back in the 1970s, Bradford was convicted of conspiracy to smuggle a “banned cancer treatment.” This actually brings me to one minor quibble I had about the Tribune article, which is that it didn’t specify the banned cancer treatment Bradford got busted for smuggling.

It was Laetrile.

That’s right. Bradford was a Laetrile peddler. How quaint. Perhaps that was so long ago that no one remembers, aside from old codgers like me (and I’m not even that old–yet). In any case, mentioning Bradford’s conviction was completely legitimate, as far as I’m concerned, because it indicates the sorts of advocates of unproven and dubious therapies who associate with chronic Lyme disease and promote all sorts of dubious treatments. Whatever condition patients suffering from the entity described as chronic Lyme disease have, such dubious treatments do them no service.

There’s one other thing about this attack piece by Raeburn that is curious. It was clearly instigated by someone who appears to have an ax to grind. Why, I asked, was Raeburn so annoyed at Callahan and Tsouderos’ article? There’s a hint at the end of Raeburn’s blog post, where which he thanks Pam Weintraub, features editor of Discover Magazine and author of Cure Unknown: Inside the Lyme Epidemic for giving him the heads-up about the Tribune article. I immediately noted that, Weintraub’s book had the contradictory plaudits from the American Medical Writers Association in the form for award for best book, 2009 and from the creator of functional medicine woo, Mark Hyman. Weintraub, it is noted, shows up within three hours of Raeburn’s post’s “going live.” It looks pretty obvious that Raeburn was asked or encouraged to post his hit piece by Weintraub and that he echoed a lot of the same attacks as Weintraub, who in the comments writes:

I am saying that you cannot quote a criminal as counterweight to a scientist, when there are scientists at major universities like Stony Brook, like UC Davis, like UC Irvine, like Berkely, who could be quoted instead, and who could present the the shades of gray and the true context for why there is all this uproar, and what these patients might be like and why they might be sick.

Except that that wasn’t what the story was about. The science is quite clear that the remedies being peddled by many of the doctors cited by Callahan and Tsouderos have been shown to be ineffective in the gold standard of clinical trials: Randomized, double-blind clinical trials. I also looked for a few of these scientists, for instance, doing Pubmed searches for investigators at Stony Brook, UC-Davis, UC-Irvine, and Berkeley. I have to admit, I wasn’t particularly impressed. For example, from Stony Brook, I saw a clinical trial from 2003 that appeared to show that antibiotic therapy was associated with improvement of debilitating fatigue. This study appears to be the very study that Callahan and Tsouderos cited as having had its blinding possibly compromised, as evidenced by the observation that more patients in the treatment group than in the placebo group correctly guessed their treatment assignment. From UC-Davis, there were a couple of mouse experiments, again not very convincing. From UC-Irvine I could find only one review article.

I could find nothing on Pubmed from Berkeley about chronic lyme disease, but maybe I didn’t persist long enough.

The bottom line is that Weintraub’s complaint is primarily also about how Callahan and Tsouderos didn’t fall for the “tell both sides” mantra that all too many journalists fall prey to when writing about dubious medicine and pseudoscience. I’m not saying that there aren’t criticisms of the Tribune article that aren’t valid, but most would be minor compared to the main messages in their article, which, as far as I was concerned, were spot on: Chronic Lyme disease is, at best, a dubious diagnosis; whatever might be the cause of category 4 Lyme disease, it does not appear to be caused by ongoing infection by the spirochete that causes Lyme disease; and there is no credible evidence that long term antibiotic therapy is effective against category 4 Lyme disease and a lot of evidence that long term antibiotic therapy has the potential to cause harm. These are the key issues, and Callahan and Tsouderos nailed them. Raeburn and Weintraub’s criticisms are nothing more than whines about how, in nailing these essential points, Callahan and Raeburn failed to fall for the trap of false balance.

This entire kerfuffle does bring up a legitimate issue, though. I complain frequently about how journalists fall into the trap of false balance when it comes to scientific and medical issues. However, it’s often difficult to explain this concept to the lay public because on the surface not giving undue voice to advocates of pseudoscience appears to go against commonly believed and taught concepts of fairness. How can a blogger, journalist, or other writer, communicate this concept in a limited space? On my blog, I can write as long or short as I want and have days, weeks, months, and even years to communicate and reinforce this concept to my readers. Journalists don’t have that luxury. I don’t pretend to have the definitive answer. No doubt different topics and different situation will require different approaches. I do know, however, that it is lazy and ultimately unintentionally deceptive to continue letting the mantra of balance result in promoting a false balance when discussing quackery and pseudoscience. As long as you can defend your position with data, science, evidence, and logic, don’t be afraid to defend science and science-based medicine.