by Steve Hickey
Practical medicine is a craft rather than science, and in the hands of the more accomplished doctors, it might even be called an art. However, it is art constrained by scientific principles and facts. Social science can be practical and helpful, but it is not normally considered a hard science. A clinical trial, for example, is a direct measure of the performance of a treatment and can suggest whether the treatment will be useful in practice, but a clinical trial is unlikely to help scientists understand the underlying pharmacology or pathology associated with the disease. When practical ideas, culture, and current practice are allowed to dominate the field of medicine, innovation and advancement are slowed. Big advances, such as Alexander Fleming’s discovery of penicillin in 1928, typically arise from observation and experiment.
The Search for “Proof”
The conventional model for good health is one in which people take regular exercise, have a diet low in fat and salt, and get their vitamin C from five daily helpings of fruit and vegetables. According to the authorities, vitamin C supplementation is unnecessary if a person eats a normal, healthy diet. Governments parade these recommendations as scientific facts. However, people who conform to these standard “healthy” recommendations can still have low vitamin C levels, get cancer, or die prematurely of heart disease. It may be that non-smoking vegetarians who exercise will die a little less prematurely, but that is hardly comforting to the majority.
People are getting fatter, eating more junk food, and taking less exercise, but, paradoxically, since the 1950s, deaths from cardiovascular disease have been falling. This recent lowering of mortality often comes as a surprise to those who rely on the popular media for information. The well-publicized risk factors, such as cholesterol, do not explain the rise and fall of heart disease in the twentieth century.27 People are bombarded with helpful information, though often it is conflicting. Mostly, it is well-meaning but based on weak evidence. The experts providing the advice often ensure that it meets currently accepted practice or, at least, is consistent with the prevailing ideas. Frequently, such advice is described as scientifically proven. By contrast, alternative medicine is portrayed as unproven. Epidemiology, supported by clinical trials, underlies these claims of scientific proof.
The finding that people with lung cancer often smoke cigarettes typifies the popular description of medical “proof.” This form of association may occasionally be useful in generating a new scientific hypothesis or be helpful in confirming a scientific finding, but it does not constitute proof.
In the first half of the last century, medical science made great strides, with the discovery of insulin for diabetes and antibiotics for infections, the beginnings of molecular biology, and advances in surgery. Since then, progress has slowed dramatically, with fewer groundbreaking therapies. Many recent advances are imports from other disciplines. X-ray computed tomography and magnetic resonance imaging have come from physics, for example. Sciences related to medicine, including biochemistry and genetics, have made steady progress, but this has not yet translated into revolutionary new medical treatments with high impacts on the major diseases.
James Le Fanu, M.D., author of The Rise and Fall of Modern Medicine, suggests that the introduction of social medicine, together with a gene-centric approach to disease, has caused this lack of progress. Medicine has stopped looking at the important data, such as the observations of Frederick R. Klenner, M.D., on the effect of massive doses of vitamin C, relying instead on indirect measures and statistics. It is as if medical science has lost the knack of finding cures for disease. By becoming dominated by the search for “proof,” medicine is giving up the scientific method. Science is a search for the explanation of how things work, not a search for something called “proof” that, by direct implication, prevents questioning. The repeated use of the term proof in medicine carries within it the suggestion of “cargo cult” science, a form of pseudo-science that has all the trappings of real science and appears to follow its rules, but is ineffective (or at least very inefficient) at expanding the knowledge base.
“Cargo Cult” Science
In 1974, the physicist Richard Feynman, Ph.D., described a phenomenon that he called “cargo cult” science.28 At that time, the magician Uri Geller had gained prominence for his claims of bending spoons, keys, and other inanimate objects with the power of his mind alone. The idea came to Dr. Feynman when Geller had been unable to demonstrate his key bending skills for Dr. Feynman to investigate. Powerless to evaluate Geller’s claim directly, he wondered why witch doctors had managed to practice for so long when a simple check on their performance would have exposed them.
Dr. Feynman remembered the South Seas people who developed what became known as a “cargo cult.” In the Second World War, airplanes brought goods and materials to the islands, landing on temporary airfields. After the war, when the planes no longer arrived, the islanders tried to reproduce the phenomenon by making new runways with small fires alongside. This provided a close approximation to what had been there before. A wooden hut for a man to sit in, wearing headphones with bamboo antennas, improved the illusion. The representation was excellent, but airplanes still did not land. However, even though scheduled flights would never land, a pilot in trouble from mechanical failure or fuel shortage might take advantage of the pseudo-airfield. Thus, the runway had reduced the risk that no future landings would occur.
The missing item in cargo cult science, according to Dr. Feynman, is scientific integrity. Scientists should always be looking out for data that does not fit. Such data explain how limited and tenuous ideas are. When alternative explanations are compatible with the data, scientists acknowledge the correspondence. The last thing a good scientist does is describe their work as scientific “proof.” By analogy, cargo cult science, based on a multitude of risk factors and asserting “proof,” looks like science, but it is not real understanding.
Scientifically, it is not possible to prove anything—science does not work like that. A scientist has an idea, called a hypothesis, such as the idea that massive doses of vitamin C can destroy cancer. The scientist then attempts to disprove or refute this idea by experimenting or by finding counter examples, and the idea may be modified in the light of new data. This process continues until the idea is shown to be wrong and can be replaced by an alternative. This approach, in its modern form, is derived from the philosopher Karl Popper. However, the method is somewhat similar in form to the Socratic method in philosophy, which involves elenchus, a cross-examination for the purpose of refutation. In practice, scientists use loose reasoning and inference to generate new ideas. If an experimental result does not come out quite as expected, there might be an alternative explanation. Experiments test these ideas, which may prove correct or may be rejected. This process of getting ideas, testing them, and throwing them away when they do not work is very powerful and has provided humanity with its expanding scientific knowledge.
A vital feature of cargo cult science is the lack of explanation. In a real airport, the controller’s headphones receive radio signals from the aircraft. This is described by basic physics, providing a rationalization for the artifact on the controller’s head. No such justification comes with the use of bamboo headphones, no matter how well-made or how closely they resemble the originals. When doctors started searching for patterns of risk and downgrading the underlying scientific mechanisms, medicine adopted the practice of cargo cult science.
The Misrepresentation of Vitamin C
There is much excitement about “evidence-based medicine” as a relatively new initiative, but this is not an indication of a scientific discipline. A corresponding phrase such as “evidence-based physics” sounds oddly ridiculous.35 Physics is a rigorous science and the idea that part of physics is based on evidence implies that some physics is not based on evidence, which seems absurd. The term evidence-based medicine is an indication that medical science is in a bad way.
As we were writing this book, the media was filled with stories
about vitamin C being ineffective against the common cold. Headlines included “Vitamin C Useless for Preventing or Treating Colds,” “C Branded the World’s Most Pathetic Vitamin,” and “Vitamin C Nearly Useless vs. Colds.” The tumult followed a minor update to an earlier Cochrane review, which contained little extra information and no new conclusions, but the insignificant update generated negative publicity throughout the world.36 The Cochrane Collaboration is an international not-for-profit organization dedicated to making up-to-date health-care information readily available. It claims to provide a gold standard in evidence-based medical studies, but prejudice and bias against vitamin C has invaded even that organization. We will look at the Cochrane study on vitamin C and the common cold as an example of medical pseudo-science.
Peptic Ulcers and the Concept of “Proof”
The example of peptic ulcers illustrates the pernicious effects of “proof” in medicine. The concept that something can be proven in science is not only wrong, but stifles progress. For example, if doctors believe it has been proven that stress causes stomach ulcers, there is no point in looking elsewhere for a better explanation. For years, it was understood that stress caused acid in the stomach, which led to peptic ulcers. People with ulcers were asked to modify their diet to include foods that made the stomach more alkaline. A basic medication was calcium carbonate, otherwise known as chalk, which would buffer stomach acid.
There was a substantial amount of data relating increased acidity in the stomach to gastritis (inflammation) and the eventual formation of ulcers. For this reason, the proposal that increased acid in the stomach could be an irritant, leading to damage, appeared obvious. The idea that excess acid in the stomach was the cause of ulcers reached a peak when the drug Cimetidine was introduced in 1976. Receptors for histamine, a local hormone associated with inflammation, were discovered in the stomach and were associated with acidity and increased risk of ulceration. Cimitedine and related drugs block these receptors, lowering stomach acid.
When medicine does not fully understand the physiology and pathology of an illness, it often relegates it to a psychological effect.29 People under stress were thought more likely to suffer from peptic ulcers, and animal studies provided additional support for the link.30 In humans, white collar workers (who were strangely assumed to be highly stressed) had the disease more frequently than manual workers did. The explanation appeared clear-cut with little reason for a scientific challenge. In recent times, a researcher might have assumed that the decades of study into this common disease had provided “proof” that stress and increased acid causes peptic ulcers. Standard physiology textbooks stated as a fact that the cause of peptic ulcer in humans was stress.31
In the early 1980s, Dr. Robin Warren of the Royal Perth Hospital, in Western Australia, found bacteria in specimens from people with chronic gastritis. Gastritis or inflammation of the stomach often happens when stomach ulcers are developing. The bacteria occurred in about half the specimens and in numbers that should have been evident on routine examination. However, these small bacteria appeared to be new to pathologists and were later given the name Helicobacter pylori. These previously unknown bacteria were in the stomachs of the majority of people suffering gastritis and ulcers. A course of antibiotics removed the bacteria, along with the ulceration and gastritis.
Helicobacter is now an accepted cause of peptic ulcer and antibiotics are a standard treatment.32 Even a low-carbohydrate diet can prevent and reverse heartburn and gastritis in many people.33 Notably, the medical establishment did not accept these findings for a number of years. The conventional explanation is that medicine is conservative and requires substantial verification before findings can become recommended therapy. More cynically, the histamine drugs like Cimetidine were still profitably under patent—they came off prescription and were available over the counter during the period in which H. pylori gained slow acceptance.
The discovery that peptic ulcer was an infectious disease has eventually been turned into a success story for modern medicine. Scientific disasters may be transformed into triumphs given sufficient time and hype. In this case, the level of incompetence was astounding. A major disease, which was relatively easy to study, was misunderstood for decades. Any doctor or pathologist examining stomach tissue could have sampled and identified the offending bacteria. This failure of medical science is clearly a result of relying on indirect evidence and not examining the disease mechanism. The concept of “proof” has no place in science, stifles innovation, and protects vested interests.34
It’s All About the Dose
The intakes of vitamin C required to prevent colds are often misunderstood. The dose-response relationship is fundamental to pharmacology: most biological responses vary with dose size. This finding is so firmly established that it barely requires repeating. However, Harri Hemilä and colleagues, who compiled the Cochrane review, apparently believe they can break the basic laws of pharmacology by using statistics.
The original findings by Frederick R. Klenner, M.D., and others were for doses of vitamin C in the region of 10 grams or more, which prevented colds in most people. Hemilä’s study considered doses above 200 mg, which is only 2 percent of Dr. Klenner’s minimum dose. The Cochrane review included three dose intervals: between 200 mg and 1 gram per day, between 1 and 2 grams per day, and above 2 grams per day. However, there were only three prevention studies with more than 2 grams a day, and each used a dose of only 3 grams.37
Some proponents of evidence-based medicine appear to think a good trial is one that obeys a specific recipe in the way it is conducted. The recipe specifies the study must be randomized with placebo controls. In the Cochrane review of vitamin C, the studies did not reach the minimum intake claimed to be effective at preventing the common cold.38 The Cochrane review, however, bizarrely considered that Linus Pauling’s vigorous advocacy for vitamin C was the stimulus for a wave of “good trials,” meaning randomized, placebo-controlled clinical trials as opposed to well-designed experiments that actually addressed the doses of vitamin C claimed to be effective. Cochrane claims these trials enabled a better understanding of the role that vitamin C plays in defense against the common cold. However, we would be extremely surprised if Dr. Pauling would have considered these so-called good trials relevant to the use of high-dose vitamin C against the common cold.
The review included doses that were both inappropriate and inadequate, with no account for the rules of pharmacology. No data were provided to indicate whether doses above 3 grams per day could be effective for preventing the common cold. Despite this, in the Cochrane report’s conclusions, data for 3 grams or less were applied to vitamin C in general, regardless of the dose. Consider, as an analogy, a study of the effects of Scotch whisky. As is well known, a glass of whisky will warm, two glasses may make a person tipsy, but a bottle or two can kill. If the Cochrane study had investigated the use of whisky, the author might have reviewed studies in which people consumed up to a fifth of a glass. Since no subjects became tipsy, the review would conclude that reports of people becoming drunk on alcohol were clearly a myth. Headlines around the world might have declared “Whisky Useless as an Intoxicant!”
If the doses claimed to prevent the common cold are large, those used to treat it are massive. A gram or two of vitamin C will have almost no effect on an existing cold or similar infection. This is not in dispute. The people reinforcing this suggestion are trying to discredit the use of high doses and, as we have explained, 1 gram of vitamin C is not a large dose. Robert F. Cathcart III, M.D., has observed that people can take much more vitamin C when they have a cold.39 Typical healthy people can take between 4 and 15 grams of vitamin C a day before reaching bowel tolerance. For a person with a mild cold, the tolerance goes up to between 30 and 60 grams. A severe cold produces an even greater increase, in the region of 60 to 100 grams, or more.40 Dr. Cathcart suggests up to fifteen divided doses per day to produce a sustained intake.41
The Cochrane study does not address the
se dosages, but uses small intakes for treatment as well as prevention. The largest dose of vitamin C in the Cochrane study was about ten times smaller than those claimed to provide an effective treatment. Hemilä and colleagues make much of the inclusion of a study that used a single 8-gram dose at the beginning of a cold, which they claim provided “equivocal benefit.” However, another study included a comparison of doses of 4 grams and 8 grams given on the first day of illness.42 The average duration of illness in the 4-gram group was 3.17 days, while in those receiving 8 grams this was reduced to 2.86 days, a significant result. These results suggest that the effect of a single dose of 8 grams is larger than the response for 4 grams. Despite the fact that a single 8-gram dose would not normally be considered sufficient for treatment, these results are consistent with repeated clinical observations of benefit for massive doses of vitamin C.