In February 2015, Christie Aschwanden, a journalist, wrote an editorial in the Journal of the American Medical Association. The article was titled, “Why I’m Opting Out of Mammography.” Aschwanden imagined five possible outcomes following the procedure: One, “most likely the scan would turn up nothing suspicious.” Two, “I’d be called back for further testing, perhaps even a biopsy for something that was not cancer,” resulting in “sleepless nights [and] some lingering worry afterwards.” Three, “the mammogram would find a cancer that would have remained innocuous if not detected. If a mammogram found one of these cancers—and right now it’s impossible to definitively differentiate them from the dangerous ones—I would be treated and ‘cured’ for a cancer that was never destined to hurt me.” Four, “the mammogram could find a very aggressive, incurable cancer—the kind responsible for most deaths. In this case, I might be diagnosed sooner, but I’d ultimately die from the cancer anyway, and I’d spend more of the years I had left receiving cancer treatment.” Five, “the mammogram could find a dangerous cancer that’s amenable to treatment, and my life would be saved.” Using data from a recent study, Aschwanden reasoned that the chance that a mammogram would save her life was about 0.16 percent. She concluded that “a mammogram is more likely to ‘cure’ me of a harmless cancer—by subjecting me to life-disrupting and potentially harmful treatments like chemotherapy and radiation—than it is to prevent me from dying of breast cancer. For me that’s a deal breaker.”
Until scientists are able to find genetic or biochemical markers that clearly distinguish bad cancers from innocuous ones, we are going to continue to suffer from the overdiagnosis and overtreatment of cancers that aren’t really cancers at all. And continue to be told that our lives are being saved when they’re not. Today, about 70,000 women every year are diagnosed with breast cancers that would never have killed them. Our overzealous sense of caution has caused a lot of unnecessary fear, anxiety, and debilitating surgeries.
7. Pay attention to the little man behind the curtain.
Today, it’s not hard to find people who give medical or scientific advice based on the Wizard of Oz effect. Health gurus all hope that their winning personalities will hide their lack of evidence. And they don’t like to be challenged. When little men behind curtains are revealed to be just little men behind curtains, they often cry foul. It wasn’t that their claims were wrong, they argue, it was that evil forces were conspiring to defeat them.
For example, in 1998 a British physician named Andrew Wakefield proposed that the combination measles-mumps-rubella (MMR) vaccine caused autism. Thousands of parents in the United Kingdom and the United States withheld the MMR vaccine. As a consequence, hundreds of children were hospitalized and at least four died from measles. The public health and academic communities responded by performing more than a dozen studies. Their findings were clear, consistent, and reproducible. The MMR vaccine didn’t cause autism. Andrew Wakefield had been wrong.
Were Wakefield a real scientist—which is to say someone who was open to the possibility that his hypothesis might be wrong—he would have looked at the mountain of evidence in front of him and stepped aside. But he didn’t. Wakefield, as it turned out, possessed something that no scientist should ever possess: a nonfalsifiable hypothesis. MMR caused autism and that was that. So he did what all pseudoscientists do when they are shown to be wrong: He found a bogeyman, claiming that other researchers couldn’t reproduce his findings because they had all been unduly influenced by the pharmaceutical industry. Wakefield wanted us believe that thousands of researchers, public health officials, academicians, and pediatricians on several continents were all deeply, hopelessly in the pockets of drug companies. Free of such undue influence, he implied, his theory was unassailable.
Linus Pauling was no different. When his hypothesis that vitamin C could treat cancer was refuted by two excellent studies published in the New England Journal of Medicine, he threatened to sue the journal. According to Pauling, the problem wasn’t that he was wrong (after all, he was Linus Pauling, the holder of two Nobel Prizes), it was that there was a conspiracy by the medical establishment to defeat him. A medical establishment that had no interest in allowing a product as inexpensive as vitamin C to replace the expensive chemotherapies it had been cashing in on for decades.
If Andrew Wakefield and Linus Pauling’s hypotheses were right, then subsequent studies would have shown that they were right. When well-designed studies refuted their claims, they chose to attack those who had found them to be wrong. They did what any good lawyer would do; they argued conspiracy. (The legal aphorism is that when the law is on your side, argue the law; when the facts are on your side, argue the facts; when neither is on your side, attack the witness.) The minute that you hear researchers claim conspiracy, you should suspect that their hypotheses are built on sand. And although their this-is-what-happens-when-you-speak-truth-to-power lament is appealing, it doesn’t mean that it’s right. As Norman Levitt, a mathematician and debunker of pseudoscience, famously said, “While Galileo was a rebel, not all rebels are Galileo”—no matter how hard they try to convince you that they are.
EPILOGUE
“History is the error we are forever correcting.”
—Anthony Marra, The Tsar of Love and Techno
When Pandora’s curiosity got the best of her, she opened the forbidden box, unknowingly allowing hunger, pestilence, sickness, poverty, crime, and vice to escape into the world. Only one thing remained—hope. When Pandora opened the box again, hope also entered the world, with a lot of catching up to do.
Today, although the terms have changed, the concepts remain the same. Now the evils released from Pandora’s box have more specific names like pests, vermin, bacteria, viruses, fungi, parasites, toxins, cancer, heart disease, and pain—all of which have inflicted suffering or limited lives. And so we fought back; our hope for a better world provided by scientific and medical advances. But our choice to push back against these evils means that we have chosen to engage in a kind of war. And, as in all wars, there have been casualties. Every advance has come with a price. Our task has been to figure out whether the price is too high. Sometimes, as has been the case for vaccines, antibiotics, and sanitation programs, the price has been small. Other times, such as for trans fats, lobotomies, and megavitamins, the price has been great. In each of these cases, the calculations have been easy. Many times, however, as has been the case for opiates and synthetic fertilizers, the calculations have been much tougher, where gains in the short term might be overwhelmed by losses in the long term.
In the end, although we hold on to the hope of a better life through science, we need to approach all scientific advances cautiously and with eyes wide open—and to make sure that we learn from our mistakes and aren’t simply paralyzed by them.
ACKNOWLEDGMENTS
I want to thank Susan Tyler Hitchcock at National Geographic for her patience and steady hand in guiding me through this book, and Louis Bell, Jeffrey Bergelson, David Gorski, Charlotte Moser, Brian Fisher, Will Offit, Bonnie Offit, Sally Satel, and Laura Vella for their careful readings of the manuscript.
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