Respectful Insolence

Over two weeks ago, I wrote a rather withering assessment of a truly bad article published by one of my favorite magazines, a magazine to which I’ve subscribed continuously since the mid-1980s. I’m referring, of course, to Shannon Brownlee’s and Jeanne Lenzer’s execrable article about the H1N1 vaccine entitled Does the vaccine matter?

I have been surpassed.

I say that because Mark Crislip has written what is to my mind the very best fisking of Brownlee and Lenzer’s article I have yet come across, entitled Yes, But. The Annotated Atlantic. Stick a fork in Brownlee and Lenzer. They’re done.

Comments

  1. #1 Kristjan Wager
    November 12, 2009

    Unfortunately, it looks like Science-based Medicine is down at the moment.

  2. #2 Todd W.
    November 12, 2009

    @Kristjan Wager

    SBM’s down for me, too. Dr. Novella, if you’re reading this, you guys really need to get a better server to host SBM!

  3. #3 Chris
    November 12, 2009

    Perhaps it is because the very volatile subjects and responses of Dr. Tuteur contributions that overload its server!

  4. #4 History Punk
    November 12, 2009

    They are far from done. This article and idiocy it ejaculates into the public sphere will forever live on in citations at SCAM sites, references by idiot mafia that run them, and Tom Harkin’s proclamations on the need for NCCAM.

  5. #5 Kausik Datta
    November 12, 2009

    4:38 EST SBM still down. Wasn’t this the new improved server?

  6. #6 squirrelelite
    November 12, 2009

    5:03 EST SBM back up, but it has been up and down a lot lately.

    It was a good post. I’m glad he fixed the typos and reposted it.

  7. #7 davenoon
    November 12, 2009

    Your post on the article was outstanding as well; don’t sell yourself short.

    In any event, Brownlee and Lenzer reveal themselves a little more completely in the Q&A that accompanied the article. I wrote a little bit about it here last week, but the short version is that they argue with a straight face that thimerosal and squalene pose possible risks to the brain and nervous system. I’d be embarrassed for them if I thought they were trying to be something other than gullible hacks.

  8. #8 Marilyn Mann
    November 12, 2009

    davenoon wrote “they argue with a straight face that thimerosal and squalene pose possible risks to the brain and nervous system.”

    I looked at the paragraph in question, and this seems like an overstatement. Here is what they said:

    “According to the CDC, none of the shots approved for use in the U.S. will contain adjuvants (substances that enhance immune reactions) such as squalene. . . . However, injected flu vaccines may contain thimerosal, a mercury-containing preservative, which many doctors believe is safe but others believe may be responsible for effects on the brain and nervous system. For people who want to take the vaccine but avoid the mercury, they can ask for single-dose vaccines.”

    There is nothing in this paragraph about squalene posing risks to the brain and nervous system. With respect to thimerosal, their statement about some doctors believing it may be dangerous is technically true. In fact, there are some doctors who say that. However, what B & L don’t mention is that those doctors are a tiny minority and at odds with the medical and public health establishment. So I’m by no means happy with this paragraph, because I think it could frighten some people.

  9. #9 Orac
    November 12, 2009

    B&L neglect to mention a lot of things in their article.

  10. #10 titmouse
    November 12, 2009

    B&L: LERN 2 SCIENTIFIC CONSENSUS UR WRITINGS!

  11. #11 matthew holt
    November 12, 2009

    Hmm….frankly I cant believe that the flue vaccine matters very much. We dont spend that much money on it, all the articles (yours, B & Ls, & Crislips) essentially agree that we dont know as much about it as we might and that it’s either a preponderance of the evidence in favor that it works (just), or that the evidence is messy and and the RCTs need to be redone.

    And it only matters in case there’s a massive 1918 style epidemic. In which case we dont have enough vaccine or Tamiflu in any case.

    I’m rather more worried about your remarks, Peter, in Los Angeles where you appear to have missed the fact that Brownlee is the spokesperson for the Dartmouth school.

    The Dartmouth school has shown for better part of four decades that doctors practicing medicine that they believe to be within the preponderance of the evidence cumulates in very bad overall results in terms of practice variation, money spent and outcomes.

    Whether the flu vaccine fits into this general thesis is somewhat irrelevant, and certainly not worth the amount of effort spent here. But this isn’t an argument between you and Jenny McCarthy, but between a serious group that has a huge body of evidence behind its basic thesis — and one you should definitely know about.

  12. #12 Phoenix Woman
    November 12, 2009

    Oh joy! Homeopath nutter Dana Ullman’s in the comments thread for that post, playing the part of the Black Knight, hollering “I’m invincible!” even as limbs are hitting the ground.

  13. #13 Matthew Holt
    November 12, 2009

    Ha ha! I thought I was posting this on
    http://scienceblogs.com/whitecoatunderground

    Hence the remarks about Peter–Sorry Orac!

  14. #14 Orac
    November 13, 2009

    The Dartmouth school has shown for better part of four decades that doctors practicing medicine that they believe to be within the preponderance of the evidence cumulates in very bad overall results in terms of practice variation, money spent and outcomes.

    Really? As opposed to what and compared to what? Doctors who practice outside of what they believe to be the preponderance of evidence? Such a statement is meaningless without something to compare to.

  15. #15 titmouse
    November 13, 2009

    Evidence is for pussies.

    Real doctors don’t need no stinkin’ EVILDENCES !!!!

    And now that I have your attention, please to buy mah liver flush.

    Or mah pastoral counseling device.

  16. #16 Travis
    November 13, 2009

    titmouse, I went to that liver flush page. Have you looked at the colon cleansing image gallery? Any idea what those things are? I’m scared, it looks like they expelled an organ or something after flushing their colon! I do love the quote
    “The death that existed inside of me”

  17. #17 Travis
    November 13, 2009

    After reading a bit about the topic and looking up that quote I came across a quality site
    (if you have a weak stomach do not look)
    http://www.ratemypoo.com/

    Maybe it is just because I am up and working at 03:15 but I could not stop laughing at that horrible, horrible site.

  18. #18 Militant Agnostic
    November 13, 2009

    With respect to thimerosal, their statement about some doctors believing it may be dangerous is technically true. In fact, there are some doctors who say that. However, what B & L don’t mention is that those doctors are a tiny minority and at odds with the medical and public health establishment.

    However, what B & L don’t mention is that those doctors are a tiny minority and are clueless cranks at odds with the medical and public health establishment.

    Fixed that for ya

  19. #19 Marilyn Mann
    November 13, 2009

    Matthew

    I don’t know what Peter said, so I can’t speak to that, but I am having trouble seeing what the Dartmouth Atlas has to do with the B&L article on flu vaccines and the critiques of that article. It seems as if you are saying that because of Shannon Brownlee’s other work, we should give the article a pass.

    And I’m not aware that flu vaccines is an area of medicine that is subject to a lot of regional variation.

    The fact that the flu vaccine — as you point out — is a relatively cheap (and safe) medical intervention is one of the reasons for using it. What’s the alternative? Shouldn’t we use what tools we have even if they are not perfect? When you weigh costs, safety and evidence for effectiveness, it seems to me that the flu vaccine comes out pretty well.

    Perhaps I am missing your point, so feel free to explain further.

  20. #20 Dan Weber
    November 13, 2009

    The only part that stuck in my mind as a decent argument from the Brownlee article was the part about there being no increased mortality in the years in which there were either huge virus mismatches or manufacturing defects.

    Unfortunately, Crislip doesn’t really address that.

    We are measuring a very noisy signal, in which the severity of the virus varies a lot year to year. But it still seems like, if the vaccine were protecting people, we would notice something significant in the years that we know it didn’t work.

  21. #21 Ed
    November 13, 2009

    Marilyn @19, Matt said @13 that he accidentally posted on the wrong thread. Prior to that post, I couldnt find the point either, but it was too late to try.

  22. #22 Joseph
    November 13, 2009

    With respect to thimerosal, their statement about some doctors believing it may be dangerous is technically true. In fact, there are some doctors who say that.

    It would also be technically true to say “some doctors believe exorcism is helpful.” I bet you some doctor, out of millions of doctors in the world, believes just that.

    Would it be intellectually sound to make such a misleading claim? I don’t think so. In fact the article makes it sound like there’s some sort of equivalence: some doctors believe one thing, others believe something else. That’s kind of like “science is just one opinion among many.”

  23. #23 Tom Murphy
    November 13, 2009

    Thanks for this blog post and others about vaccines. I made a new video called YES They Did! Swine Flu (H1N1) Shots for Obama Girls and someone brought up the Atlantic article so I added a link to this blog post and to several others of your posts on this subject.
    If anyone wants to help counter the misinformation, please watch my video at the above link and pass it on.

  24. #24 Pablo
    November 13, 2009

    But the doctors who are anti-thimerisol are unappreciated geniuses. Just ask them! I mean, Jay Gordon is still around, right?

  25. #25 Tom Murphy
    November 13, 2009

    Oric, did you delete my comment about my H1N1 video which helps debunk anti-vaccine propaganda? Here is the link: http://www.youtube.com/watch?v=F_LJSYTgFfQ

  26. #26 Shay
    November 13, 2009

    (with profuse apologies to Fats Waller):

    Don’t want no squalene
    No mercury
    No toxic vaccine
    I’m keeping my kids pharma-free;
    They don’t need that shot
    I’m not afraid of flu.

    Their Grandma’s certain
    Those jabs are bad
    Don’t need no hurtin’
    Arms on kids, it makes them sad;
    They don’t need that shot
    I’m not afraid of flu.

    My obstetrician
    Said not to miss ‘em;
    But dad’s boss’ cousin knows that they kill!
    Jim and Jenny claim they’re harmful too–
    (I believe them).

    To a flu party
    My kids will go
    I’m such a smarty
    Plus I’m a mom and I just know
    They don’t need that shot;
    I’m not afraid of flu!

  27. #27 Marilyn Mann
    November 13, 2009

    @Joseph

    Please reread my comment, especially the last two sentences. You seem to have misunderstood my intent.

  28. #28 Deech56
    November 14, 2009

    What an excellent post from Dr. Crislip. It provides a window into how researchers, especially those who perform clinical research, and physicians tackle the difficulties of actual research. There are so many lessons for anyone trying to see what scientists actually do when face with complex systems.

  29. #29 Jennifer B. Phillips
    November 14, 2009

    And SBM is down again, Sat AM. How frustrating! I thought Mark Crislip’s take-down was masterful, and I was planning to send the link to some friends who were a bit freaked out by The Atlantic piece. Oh well…

  30. #30 Antaeus Feldspar
    November 14, 2009

    I’ve already read Mark Crislip’s excellent deconstruction of the Brownlee and Lenzer article. Frankly, just reading the bit about how others “cannot ignore the fact that [Tom Jefferson] knows the flu-vaccine literature better than anyone else on the planet”, I knew this was an article not to be trusted. How could one ever even make a determination that “X has read the literature more thoroughly than anyone else on the planet”? And merely having read documents doesn’t mean one “knows” them.

    The one thing that I haven’t seen any review of the article address, though, is the claim that in the years when the strains in the vaccine were poor matches for the strains in the wild, none of the negative consequences that we would have expected from such a mismatch were observed. I would be quite interested if someone were able to clarify how much of that claim is the truth and whether there’s anything significant that they omitted.

  31. #31 RJ
    November 15, 2009

    The Atlantic article is up (as a link) on HuffPo now. I would guess that most of the anti-vaccine/pro-infectious disease folks there have already seen it, but now we can expect the rest to use it to validate their belief system. My guess is that they won’t read the analysis by Crislip. Too bad, it is very well written and addresses the holes in the article.

    What is the deal with this Jefferson dude anyway?

  32. #32 titmouse
    November 15, 2009

    What is the deal with this Jefferson dude anyway?

    Ever go to a large scientific conference at some hotel or convention center? You first visit the registration desk to pick up your name badge. Keep this in mind as you read this excerpt from the Atlantic article:

    At a 2007 meeting on pandemic preparedness at a hotel in Bethesda, Maryland, Jefferson, who’d been invited to speak at the conference, was not greeted by any of the colleagues milling about the lobby. He ate his meals in the hotel restaurant alone, surrounded by scientists chatting amiably at other tables. He shrugs off such treatment. As a medical officer working for the United Nations in 1992, during the siege of Sarajevo, he and other peacekeepers were captured and held for more than a month by militiamen brandishing AK-47s and reeking of alcohol. Professional shunning seems trivial by comparison, he says.

    International scientific conventions are a sea of unfamiliar faces. Most attendees only know a small sub-set of their colleagues by face.

    If you find yourself at one of these scholarly gatherings eating an over-priced turkey wrap all by yourself, and you imagine that people sitting or wandering nearby are intentionally shunning you, you are psychotic.

  33. #33 JohnV
    November 15, 2009

    That pretty much describes my conference experience. Who knew it was because my colleagues were shunning me. I just thought it was because I didn’t know anyone and am more or less crippled by introvertedness.

  34. #34 Prometheus
    November 15, 2009

    Matthew Holt (#11) makes an interesting comment:

    “Hmm….frankly I cant believe that the flue [sic] vaccine matters very much. We dont spend that much money on it, all the articles (yours, B & Ls, & Crislips) essentially agree that we dont know as much about it as we might and that it’s either a preponderance of the evidence in favor that it works (just), or that the evidence is messy and and the RCTs need to be redone.”

    I’m at a loss to see how the fact that the influenza (or “flu”) vaccine is inexpensive is related to its efficacy. I also am at a loss to understand how Mr. Holt came to the startling conclusion that the “evidence” (is that the same as “data”?) is “just” in favor of the vaccine “working”.

    Although Tom Jefferson of the Cochrane Collaboration has some reservations about the utility of influenza vaccination (he argues that effectiveness isn’t the same as efficacy), other studies show that the vaccine is effective at preventing influenza in all populations (except children under 2 years old – a group that hasn’t been adequately studied).

    Now, the test of efficacy is usually made by antibody titre, so those people who believe that antibodies don’t prevent infection will probably choose to ignore them. However, given the dizzying number of non-influenza viruses that cause symptoms similar to (if usually of lesser intensity) influenza, the rapid antigenic shifts the influenza virus is capable of and the naturally large variation in exposure (especially in communities where large numbers of people are vaccinated), looking at actual prevent-the-flu efficacy can be hard to ascertain.

    Of course, it is in the nature of science that “…we dont [sic] know as much about it as we might…” – if we did, we’d stop doing research. However, I think it is reasonable to say that we know enough about the influenza virus and its vaccines to say that they are an effective way to prevent influenza.

    Prometheus

  35. #35 T. Bruce McNeely
    November 16, 2009

    t would also be technically true to say “some doctors believe exorcism is helpful.” I bet you some doctor, out of millions of doctors in the world, believes just that.

    You are (or were) correct. The late M. Scott Peck, the psychiatrist who wrote “The Road Less Travelled” did in fact credit exorcism with curing a few of his patients. He wrote about this in “People of the Lie”, I believe.

  36. #36 titmouse
    November 16, 2009

    He wrote about this in “People of the Lie”, I believe.

    Yes, sadly.

    Peck offers some interesting commentary on the nature of evil in the first part of the book, using a few case reports from his own experience to illustrate. I rather liked that part. But in later chapters he goes off the rails, making it hard to recommend the book generally.

    The demon theory of mental illness went hand-in-hand with the humoral theory of disease. Both conjectures satisfy a human intuition that illness results from a toxic substance or evil entity within the body, and therefore removal of the substance or entity should result in a return to health.

    Doctors are human and more or less subject to the same compelling but delusional intuitions as everyone else. That’s why in the search for truth it’s not helpful to believe in or be a fan of particular doctors.

  37. #37 Dan Weber
    November 16, 2009

    The one thing that I haven’t seen any review of the article address, though, is the claim that in the years when the strains in the vaccine were poor matches for the strains in the wild, none of the negative consequences that we would have expected from such a mismatch were observed. I would be quite interested if someone were able to clarify how much of that claim is the truth and whether there’s anything significant that they omitted.

    I really would love to see a response to your question, but I haven’t seen one. When Hib or measles vaccines drop off, we get kicked in the teeth with the bad results.

    I have had to come up with answers on my own for why there aren’t increases in mortality when the flu vaccine breaks, but they all leave me feel like I’m begging the question. Anyway:

    * It is hard to measure flu deaths in the first place. Deaths with flu-like symptoms significantly overcounts in some ways and undercounts in other ways.

    * The strength of the flu varies a lot from year to year.

    * For the years in which the vaccine was for the wrong strain, the act of being vaccinated against another strain may still provide some resistance to infection or passing it on.

    * For the year in which there were manufacturing problems and a shortened supply, people were aware of the increased risk and took other countermeasures.

    These are all plausible, but I don’t feel right just asserting them and saying the issue is done. Is there an objective (if imperfect) measure of the strength of a flu strain besides how many people it kills in total? Is there a way to measure those countermeasures, such as polling data? (If not for the past, than how about going forward?)

  38. #38 riv
    November 17, 2009

    http://mail.google.com/mail/?ui=2&ik=1e2ad5bfd9&view=att&th=125007202fbf8dc1&attid=0.1&disp=vah&zw

    Swine flu, better natural immunity than artificial one

    SWINE FLU VACCINE (IF IT WORKS) MAY AVOID NATURAL IMMUNITY THAT LASTS FOR MORE THAN 50 YEARS

    Published as: Gérvas J, Wright J. Future of flu vaccines: please, may we have a RTC now? British Medical Journal 2009;339:b4651.

  39. #39 Chris
    November 17, 2009

    So you linked to your google mail box? It looks like a commentary.

  40. #40 Chris
    November 17, 2009

    Just a reminder: finding one lone commentary or paper that confirms you bias is called “cherry picking.”

    By the way, there is an interesting discussion on flu vaccine and children on the latest This Week in Virology podcast. I cannot read the BMJ commentary you thought was so important, but I think you might find the podcast interesting.

    Also, another podcast that should interest you is the Special H1N1 Pandemic Skeptic’s Guide to the Universe Podcast. It is both educational and entertaining.

  41. #41 Energy
    November 20, 2009

    A good example of “correcting” faulty DNA with laser energy would be the laser ablation of malignant and pre-malignant skin lesions. The DNA is “corrected” in the sense that the genetic aberrations in these malignant and pre-malignant cells are eradicated – along with the cells, themselves.

    So you see, it’s all true – in the right circumstances.

    However, their lame LED laser-wanna-be isn’t capable of doing any of that.

    Prometheus