Six medical “myths” that aren’t

I usually don’t do requests, at least not very often. As selfish as it might sound, I do this blog mainly to amuse myself, which means that I choose whatever topics interest me and write about them. Believe it or not, I’d probably still be doing this even if my readership were 1/100 of what it is. After all, I did it seven years ago before anyone had ever caught on to the glory (and ego) that is Orac. I’ve just been fortunate in that, for the most part, the topics that interest me enough to write about them are generally interesting enough to a bunch of people every day to read them. That confluence between my interests and my readers led me to finding myself a very nice little niche in the medical/science/skeptical blogosphere. And there was much rejoicing, except among quacks and anti-vaccine loons.

Sometimes, however, my interests align with my readers’ requests. Several of you actually sent me the topic to which I’m about to lay down a heapin’ helpin of not-so-Respectful Insolence. Its source? Where else? It comes from that wretched hive of scum and quackery, The Huffington Post. It’s by someone by the name of Dr. Robert A. Kornfeld, who bills himself as the “founder of the Institute for Integrative Podiatric Medicine.” That alone at least brought me a chuckle. I know, I know, mentioning that could be construed as an ad hominem attack, and, given the content of his post, ad hominems are not necessary. Dr. Kornfeld’s post is what we in the biz call a “target-rich” environment. There’s so much material there that it doesn’t matter who or what Dr. Kornfeld is, although it was fun to take a peak at the website for the Institute of Integrative Podiatric Medicine. It’s all there: homeopathy, anthroposophic medicine, functional medicine, and homotoxicology, among others. But what really made me go beyond chuckling into uproarious laughter was the title of a conference that Dr. Kornfeld hosted a few years ago:

NUTRIGENOMICS and INFLAMMATION: A Science-Based Seminar for the Progressive Podiatric Physician

“Science-based.” Dr. Kornfeld keeps using that term. I do not think it means what he thinks it means. And he proves it with his HuffPo post 6 Medical Myths Even Your Doctor May Still Believe. These six “myths” are all either overstatements, exaggerations, or straw men representations of what science-based medicine concludes. Let’s start with “medical myth #1”:

Myth #1- Technology has improved healthcare

Ask any physician if he believes that technology has improved health care and you will get a resounding “Yes!” Advances in medical technology now enable us to look inside the human body with relative ease and with great detail. Our surgical tools allow us to operate on all parts of the body with a minimum of trauma and blood loss. Technology has helped us improve the quality of life for millions of patients every year. It has enabled us to save countless lives as well. Therefore, it is certainly a foregone conclusion that technology has, in fact, improved our health. Or has it?

While there is something to be said about whether physicians sometimes rely too much on technology, as in overusing imaging studies for diagnosis to the detriment of skills taking histories and doing physical examinations, it’s hard to argue that technology hasn’t improved health care in many, many ways. For example, in my field, laparoscopic and endoscopic surgical techniques have allowed surgeons to be able to do operations that used to require large incisions and many days in the hospital through tiny incisions or even using no incisions at all, allowing for faster recoveries with at least the same, or even better, results. Imaging studies allow earlier diagnosis of cancer and other diseases. True, as I’ve discussed, in some cases this leads to overdiagnosis and overtreatment, but finding disease earlier often allows for less invasive, less morbid treatment with fewer side effects and better outcomes. I suppose Kornfeld could be talking about overdiagnosis when he claims that there are “more cases of cancer, heart disease, arthritis, auto-immune illnesses, endocrine disorders, developmental disorders, allergies, respiratory problems, infectious diseases, neurological problems, musculo-skeletal pathology, gastro-intestinal disorders, psychological illness, etc., than ever before,” but it’s arguable that this is even the case. If you look at the incidence of many cancers, while there are some whose incidence has increased, the incidence of most others is either flat or decreasing. Ditto heart disease, where the incidence of heart disease and stroke have been pretty stable for the last 13 years or so. Meanwhile, mortality due to cardiovascular disease has been plummeting. Arguably, a lot of the reason for that is technology.

All of which points to Kornfeld’s ignorance when he asserts:

If anything, advances in technology have fostered a narrow field of vision, focused more on early detection and intervention than on prevention. If, by definition, health care means “the maintenance of good health,” then technology has failed miserably to produce any measurable improvement in the overall state of health of mankind.

Actually, I would argue that early detection and intervention can often be a form of prevention. For example, if doctors detect hypertension early, treating that hypertension goes a long way towards preventing its complications, which include stroke and myocardial infarction. Moreover, it’s a false dichotomy being presented to imply that we either have technology focused on early prevention, less invasive therapy, and better diagnosis or we have prevention. We can have both, and in fact it’s not always easy to tell where the boundaries are between prevention and early detection. More importantly, whether or not we have had any improvement in our state of heatlh depends a lot on how you define “health.” People with chronic conditions are living longer with better quality of life than ever before.

Let’s move on to “myth” number two:

Myth #2 – Inflammation is bad

Ask any doctor what to do about inflammation and the answer will be a uniform, “Take an anti-inflammatory.” While it is true that taking medication to suppress inflammation can certainly lead to increased comfort, should we be doing that in the first place? Is inflammation bad? Is it something that occurs by freak accident, some physiologic aberration, that occurs and causes great distress and suffering amongst mankind? We have been conditioned to think of inflammation as something bad because it causes pain and makes us miserable, therefore it should be medicated and suppressed. Right? Wrong.

Inflammation is a directed response by the immune system designed to detoxify, repair and protect tissues under any form of functional or metabolic stress. It is important to understand the purpose of inflammation in order to see why we should not work to suppress it, but rather to support it.

First off, it’s a massive straw man to claim that SBM argues that “inflammation is bad” in general. In fact, in my very first week in medical school, we were taught how inflammation is a normal homeostatic bodily response to injury or physiological derangement. Indeed, inflammation is the basis of all healing. If you cut yourself, it is the inflammatory response to that injury that ultimately leads to its healing. Truly, the body’s ability to heal itself is amazing, and inflammation is what mediates that healing.

The problem is not inflammation per se. It’s when, for whatever reason, inflammation somehow gets out of control, when it becomes chronic. In fact, chronic inflammatory reactions are at the heart of quite a few diseases and conditions, including atherosclerotic vascular and cardiac disease as well as many cancers. Ever hear of Marjolin’s ulcer? Basically, it’s skin cancer that develops in the area of an old burn injury due to–you guessed it–chronic inflammation. Then there’s esophageal cancer, which frequently develops in a condition known as Barrett’s esophagus, which is basically a chronic inflammatory reaction of the lower esophagus to stomach acid refluxing up and hitting the mucosa of the esophagus, and, yes, Barrett’s esophagus predisposes to the development of esophageal cancer.

It’s also hard not to point out that Kornfeld is a massive hypocrite on this issue. Here in his HuffPo piece he is extolling the benefits of inflammation, how it’s necessary for the body to be able to “detoxify,” and how we should “support it.” Yet right on his website is a paean to a conference he held back in 2005. Remember what it was called? That’s right, it was called NUTRIGENOMICS and INFLAMMATION, and it’s all about using nutrition to suppress inflammation:

From the perspective of integrative medicine, Dr. Kornfeld will teach you how to intervene on behalf of gene expression with regard to inflammation and chronic degenerative disorders.

Yes, Dr. Korfeld himself appears to have no problem with trying to suppress and modulate inflammation. True, he’s not using drugs to accomplish this. Rather, he thinks he’s using diet to do it. But he’s doing it all the same, or at least trying to do it. (It’s arguable whether all the dietary woo promoted by “integrative” practitioners like Kornfeld actually do anything whatsoever for chronic inflammation.) Of course, Kornfeld doesn’t see it this way. He thinks he’s “modulating” inflammation naturally:

What makes more sense, empirically, is to treat these problems mechanistically and supportively. In other words, we want to work to help make the pathway of primary inflammation more efficient, with supportive, rather than suppressive, protocols. There are many natural medicines that can help accomplish the task of supporting our bodies, be they homeopathic, nutritional or herbal. Additionally, we want to be able to identify the reason(s) that this pathway is not functioning efficiently.

On the other hand, maybe Kornfeld is advocating letting inflammation take its course. After all, he is recommending homeopathic remedies. Nope. not really. Check out his blog, where he lists five ways to reduce inflammation “naturally.” He even admits:

Unfortunately, when chronic inflammation remains for long periods of time and is not addressed adequately, it will cause the expression of genes that lead to degenerative conditions such as coronary artery disease, arthritis, cancer and others.

While in many cases, anti-inflammatory medications are prudent and potentially life saving in patients with certain conditions such as cardiovascular disease (for example aspirin has been shown to prevent heart attacks) and auto-immune inflammations (when treated with anti-inflammatory medications, these patients can experience improved quality of life), it is still very common for doctors and patients to take a rather cavalier attitude toward prescribing and consuming these medications.

It sure sounds as though Dr. Kornfeld accepts that “inflammation is bad” in many clinical situations. At least, chronic inflammation certainly is. So basically, in the name of seeming to be “smarter” than conventional medicine, Kornfeld is actually trying to do the same thing. Only he won’t admit it and he’s trying to do it with pseudoscience, all the while claiming without basis that he somehow understands physiology better than physicians.

Certainly he doesn’t understand genetics, as the next “myth” demonstrates:

Myth #3 – Genetically coded diseases are unavoidable

This is, of course, a massive straw man argument. It’s also based on an even more massive misunderstanding of genetics:

If having a gene for any illness condemns you to having that disease, then why are you not born with the disease you are coded to have? Why isn’t every person who carries a gene for disease suffering at all times from that disease? The answer is that all genes do not express themselves at all times and many never do. There must be a reason why the body would call upon a gene to express itself. Otherwise, none of us would be able to survive the onslaught of genetic expression. So what is it that causes a gene to express itself? If you consider for a moment that diseases are just a complex of symptoms being incorporated by the body in an attempt to protect itself from tissue destruction and/or imminent death, you may begin to get a clearer understanding of what I am trying to say. Once we begin to pay attention to the reasons that a gene might express itself, we may be able to prevent that gene from releasing its code for illness.

First off, Kornfeld seems to keep saying “gene” when he means “allele” or “gene mutation” in referring to a “gene for any illness.” If he doesn’t get his basic terminology right, it’s hard to take him seriously. He also seems to have no clue about what regulates gene expression if he finds it in any way amazing that alleles or mutations associated with disease don’t cause disease right at birth. He’s clearly unfamiliar with the astoundingly complex temporal regulations of genes controlling development, right from embryogenesis up through childhood and then into adulthood. This temporal regulation of gene expression and action occurs over years, decades even. And it’s completely normal.

I also have no idea what the heck Kornfeld means when he says we “may be able to prevent that gene from releasing its code for illness.” It makes no sense. Genes encode proteins. Sometimes there are heritable mutations in those genes that predispose to illness (such as various BRCA1 mutations that hugely elevate a woman’s risk of breast and ovarian cancer) or outright cause illness (sickle cell trait/anemia or inborn errors of metabolism, like phenylketonuria, for example). True, many of the mutations that directly result in disease do produce the disease from birth (again, the examples of sickle cell trait (which only requires one copy of the mutated allele as compared to sickle cell anemia, which requires two) or phenylketonuria. Kornfeld seems to be assuming that, if a mutation or allele doesn’t cause disease right from birth, the way that inborn errors of metabolism do, then people must have an enormous degree of control over whether whether those genes ever “release their code for illness.”

Nonsense.

Take the example of BRCA1 mutations that predispose to breast and ovarian cancer. Certain of these mutations can produce up to an 80% lifetime risk of developing breast cancer, and there’s very little that can be done to reduce that. Actually, that’s not entirely true, but, whatever can be done to reduce the risk of breast cancer in BRCA1 mutation carriers, diet isn’t going to make a significant impact; nor is exercise. Nor are any supplements that you can think of–or any of the other woo that Kornfeld touts. The only interventions that can reduce the risk by more than a small percentage are prophylactic surgery to remove the breasts or possibly Tamoxifen, no doubt in Kornfeld’s eyes an evil pharmaceutical drug. In some cases, genetics really does trump everything. Just because baby girls with BRCA1 mutations don’t have breast cancer when they are born doesn’t mean that breast cancer can be prevented by Dr. Kornfeld’s woo in women with such mutations.

The worst part of this whole bit of nonsense is that Dr. Kornfeld appears to be pulling the old “blame the victim” gambit. I’ve written many, many times the dark side of the “empowerment” that promoters of “alternative medicine” like to tout when they ascribe near magical powers (actually, there’s no “near” about it) to lifestyle, diet, and the like is that, if you are responsible for being in perfect health, you are likewise responsible if you aren’t in perfect health. It’s something I’ve referred to as the “illusion of control,” and it’s very pernicious. Kornfeld is not as blatant about it as Robert O. Young has been in expressing this idea, but it’s the same basic undercurrent to the same basic idea, namely that if you are sick it is your fault. You are to blame. Not nature. Not a “germ.” Not genetics. You. Kornfeld even makes it explicit:

You should be beginning to see the pattern here. Are we treating cancer by cutting it out? Are we treating arthritis by suppressing the protective inflammation brought about by years of free radical damage? Does coronary artery bypass grafting cure cardiovascular disease? Of course not. Our goal should be in maximizing understanding of cause and effect and employing life affirming, nutrient-rich diets with a healthy, wholesome, natural lifestyle. This is the way to “prevent” genetically coded diseases.

Except that inflammation is not “protective” anymore after a certain point. In any case, the point is that Kornfeld apparently thinks that diet and exercise and whatever woo he is into can somehow trump biology. There’s no doubt that lifestyle can have a major effect on health, sometimes even in the case of genetic predispositions, but in most cases biology will ultimately win out.

On to myth four:

Myth #4 – Medications improve health

And why? Dr. Kornfeld explains:

First of all, every medication swallowed is perceived by the immune system as a “poison,” because there is nothing in nature that would ever present to the G.I. tract in that form of chemicals. This added “toxic load” places additional stress on the body. These chemicals must be detoxified and eliminated by the body. This need to detoxify causes stress in the liver and kidneys and can damage these vital organs.

Well, yes. Sort of. My very first day of pharmacology class in medical school, I remember the professor telling us that all drugs are poisons in that they interfere with a normal physiologic function or intracellular molecular signaling pathway. So what? When normal physiology is disrupted, often the way to restore homeostasis is to interfere with the signaling pathway that is overactive or to try to compensate by blocking another pathway. It’s also utterly ridiculous to claim that there is “nothing in nature that would ever present to the GI tract in that form of chemicals.” Do I really have to point out how many drugs that we use are derived from plants and natural products, how many drugs are actually found in nature? All pharmaceutical companies do is to purify and standardize these drugs. I suppose it all comes right back to the naturalistic fallacy. Drug found in nature = good; drug found in nature purified and placed in a pill = bad. I suppose Dr. Kornfeld would recommend that we chew on willow bark instead of using aspirin or eat foxglove leafs instead of taking digoxin.

Another thing popped out: What the hell does Dr. Kornfeld mean by saying that the “every medication is perceived by the immune system as a poison”? In most cases, exceptions being large molecules that are immunogenic, the immune system has nothing to do with whether a drug is “perceived” by the body as a “toxin” or not. Clearly, Dr. Kornfeld’s ignorance about immunology rivals his ignorance about genetics and that combined ignorance leads Dr. Kornfeld to opine:

So, what am I saying here? Quite simply, if a patient has high blood pressure and is taking medication to control it, and then they cease taking it, they will see their blood pressure rise again. If they are suffering with an inflammatory problem and are taking anti-inflammatories to control their discomfort, and cease taking their meds, they will again be in pain. If they are suffering with sinus congestion and take a decongestant, they will feel congested again if the drug is withdrawn. Empirically then, we see that the medication has not at all improved their health, just their symptoms.

Except that hypertension is in most cases completely asymptomatic, which is one reason why reating hypertension is a perfect example of prevention I can think of, as I discussed above. By the time someone gets symptoms from his or her hypertension, it’s often too late, because that symptom will be angina, a myocardial infarction, a stroke, or symptoms of ischemic peripheral vascular disease. Sometimes, sudden death from a heart attack is the very first symptom that anything is wrong. That’s one reason why treating hypertension is improving health.

On to “myth five”:

Myth #5 – Childhood immunizations protect us from serious disease

Of course. You knew it was coming: Anti-vaccine wingnuttery, which goes together with woo like peanut butter goes with jelly–or like dingle goes with berry. I’m only surprised that it took Kornfeld until the fifth myth to get to it and let his anti-vaccine freak flag fly high. Maybe he was restraining himself. Be that as it may, I don’t plan on spending too much verbiage on this one. Basically, Kornfeld regurgitates many common anti-vaccine tropes that I’ve dealt with for the last seven years on this blog. He does concede that vaccines save lives (albeit after claiming that most children recover from most of the diseases protected against, except polio, both assertions demonstrating how little he understands). I’ll give him that much though; he does accept that vaccines save lives. Many anti-vaccine prone woo-meisters refuse to admit even that. There is, of course, a “but” added, and in Dr. Kornfeld’s case that “but” is the question: “But at what price?” He states:

Rather than decreasing childhood morbidity and improving the health of all subsequent generations being immunized against these diseases that have affected mankind for thousands of years, we have instead seen a dramatic rise in childhood illness in the form of ADD, ADHD, autism, allergies, learning disabilities, infectious diseases, auto-immune illnesses and, most importantly, cancer. Cancer has been on a frighteningly dramatic rise in small children over the past decades and shows no signs of letting up. Mortality rates for childhood cancers are unacceptably high although technology has slowed the course of death.

Wow. He actually one-upped a lot of anti-vaccine activists in this one. I’ve heard all the scientifically unsupported claims from anti-vaccine activists that vaccines cause allergies, autism, ADHD, diabetes, and the like, but I’ve never seen a claim that vaccines are somehow responsible for the increasing incidence of childhood cancers. Bring on the pirates again! While it is true that childhood cancer has increased in incidence since 1975, the reasons are unclear. One thing that’s for sure is that there is no credible evidence that vaccines have anything to do with this increase. In any case, the increase in incidence of childhood cancers is bad, but what’s good is that mortality from childhood cancers has fallen dramatically since 1975, and, conflicting with Dr. Kornfeld’s “myth number one,” it’s been largely medical technology that’s done it. Kornfeld even admits as much in the paragraph above, albeit apparently grudgingly! In fact, one wonders whether Kornfeld would prefer that those children should die, given that he uses frankly eugenicist arguments:

Have we traded off less serious illness for more devastating disease? How did mankind survive and thrive through thousands and thousands of years without being immunized? Are we interfering in a way that has created a weakening, rather than a strengthening, of the human immune system? Is it possible that we are interfering with the natural course of genetic mutation that would have rendered authentic immunity to these diseases?

In other words, it’s better to let children die of vaccine-preventable diseases because it’s evolution in action, culling the “weak”–naturally, of course. Think I’m being too harsh? I don’t.

Finally, there’s “myth six”:

Myth # 6 – The double blind – placebo controlled study guarantees safety and efficacy in drug therapy

Now there’s a straw man for you. No one says that the double-blind, placebo-controlled randomized clinical trial (RCT) guarantees safety and efficacy in drug therapy. No one. What scientists do say is that the best current methodology we have to evaluate the efficacy of new drugs is the RCT. If RCTs were thought to “guarantee” the safety and efficacy of new drugs, then there wouldn’t be a need for post-market surveillance for adverse reactions that can’t be detected in RCTs because there aren’t enough subjects in them, nor would there be a need for phase IV trials, which are carried out after a drug is approved by the FDA and released into the market. Contrary to Kornfeld’s characterization, real scientists and real regulatory agencies (like the FDA) recognize that RCTs can’t detect all adverse reactions and drug interactions and are continually trying to find ways to identify problems that weren’t detected during phase III RCTs. Is the process perfect? Of course not. Could it be improved? No doubt. Does Kornfeld suggest ways to improve the system?

Nope.

Instead, he rants about how RCTs don’t detect all the uncommon side effects of drugs or interactions with other drugs as though that were a failure of the entire system. He ignores all the other forms of clinical trials, post market surveillance, and phase IV trials that look for just these problems after a drug is marketed. One wonders what Dr. Kornfeld would propose in the place of the current system; increasing the number of patients required in phase III trials in order to pick up rare adverse reactions would require a lot more money to develop each drug, and the process is very costly to begin with. No matter what system we come up with, it will never be perfectly safe and completely foolproof, which is what Dr. Kornfeld seems to demand. It will always be a compromise between safety and economics. One could certainly make an argument for reforms of the current drug approval process to tilt it more towards safety, but Dr. Kornfeld doesn’t propose any. Rather, he tries to imply that the system doesn’t work and that therefore you should choose his woo instead of drugs. It would be very interesting to see, in an ideal world where Dr. Kornfeld could design a drug approval system from the ground up, exactly what evidence of efficacy and safety he would require before the approval of a new drug. Certainly, given that he uses homeopathic remedies, his standards for efficacy must be very, very low indeed.

Overall, Dr. Kornfeld is just another anti-science crank attacking science-based medicine because it doesn’t support the efficacy of the various forms of quackery. We’ve seen his like many times before. No wonder he’s found a home on HuffPo.