A blog about science, medicine, media and the ramblings of Irish hack....

Tuesday, March 11, 2014

Health policy must be formed on the basis of evidence, not scaremongering..

A cautionary tale of sorts and an urgent plea to Irish politicians to check their sources before they go and make asinine claims and set bad policy on matters of science of health ..

There are certain topics I write about that generate howling letters of disapproval. Topics like abortion, climate change, secularism, gay rights, nuclear power, and homeopathy have all garnered me angry tweets, emails and in some more disturbing cases long rambling letters with vague threats. I accept this as an occupational hazard - the more prominent your forum, the more likely you are to get projectiles lobbed at you and while that's never justified I accept it for what it is - I'm extremely privileged to be both lucky and ostensibly articulate enough to get the odd say in two prominent papers, and hopefully have been able to sway some people towards an evidence-based approach to certain topics, which has always been my primary goal in writing for a mainstream audience. I am no shrinking violet and usually laugh off the odd unhinged e-mail or tweet that some eijit decides to send me - the kind of emails that have have sections WRITTEN IN ALL CAPS and a grasp of logic so tenuous that you stand dazzled and almost impressed by their brave refusal to be a confined to anything even remotely resembling reality.

Yet of all the contentious issues I've tackled, the vitriol I've garnered for water fluoridation is both impressive and admittedly baffling. It is also a subject that showcases the combined scientific ignorance of many of our elected representatives, and for that reason I wish to revisit it and ram this point home. Back in September 2013, a number of Irish senators made some alarming claims about the damage fluoride was doing. Hotpress magazine were running scare stories based on the claims of self-described scientist Declan Waugh. However, the portents of doom were simply not supported by the data - the epidemiological evidence is not even remotely ambiguous- fluoride has been shown for decades to be beneficial to dental health in the correct concentration, saves much more than it costs and in the recommended concentrations has no serious side-effects. The WHO recommend about 1 mg / L for optimal benefit. Ireland stands at 0.7 mg / L, below even the recommended level. Frightening claims claims of cancer, bone disease, autism and pretty much everything else under the sun being linked to fluoride in water are simply not supported -or outright contradicted- by medical evidence. Waugh's charges themselves had been considered - and roundly slammed by the Irish expert board on fluoride. Dr Seamus O'Hickey of the Irish Expert Board on Fluoridation and Health examined the claims and concluded "... in spite of its presentation, its content is decidedly unscientific..the allegations of ill health effects are based on a misreading of laboratory experiments and human health studies, and also on an unfounded personal theory of the author’s.".  The report summary is found here and is pretty damning - this should be a major red flag; in science, the conclusion must fit the evidence. It is profoundly unscientific to start with a conclusion and bend the data to fit it.  

Despite the rebuke from the IEBF, the issue just wouldn't go away and each week worrying claims would pop up in regional newspapers. Seeking to readdress this balance, I wrote a little analysis of the situation for the Irish Times. I've written about the vehement and passionate response this generated here.  [Note - In  Irish Times op-eds, I'm limited to 800 or so words which doesn't always give me scope to deal with all specific claims - Journalist Gerry Byrne recently wrote a pretty scathing analysis in the Sunday Times on Waugh's claims, and his blog post on the subject is worth reading if you want specifics of why such claims are bogus ]. I considered it a fringe issue and in many respects a waste of time. That should have been the end of it; except in November, Sinn Fein TD Brian Stanley tabled a motion  calling for the removal of fluoride in water based on these long since discredited scare claims. He was supported by a handful of other TDs, including Luke Ming Flanagan and Clare Daly., who parroted the same old empty rhetoric. This was doubly disappointing for me, as since I was old enough to vote I've always cast one for Daly - a policy I will sadly not be repeating any time soon.

Luke Ming Flanagan at a publicity stunt strip off to raise money for "The Girl Against Fluoride" - I don't even....

Around this time I got a call from George Hook's producer to debate Brian Stanley on air. By this stage I was irked; Health policy should be made on the scientific evidence, not based on people's irrational fears. The oft-repeated nonsense about fluoride has been scientifically thrashed for decades. As elected Representatives on €92,672 plus expenses a year I supposed I had held some vague hope that politicians might do their homework before making worrying pronouncements that 5 minutes on wiki-fucking-pedia would have nullified, but it would appear this is too much to ask. Fluoride is in some respects a sideshow; the crux of the matter is that if we base our decisions on emotive and poorly formed ideas, everyone suffers. This is especially true in health, as should be clear to anyone who remembers the cost in human suffering if misinformed panic over vaccination a decade ago - suffering that, incidentally, is still ongoing. With this in mind, I agreed to partake in the debate.

I met Brian before the chat- he was an affable guy, but it was immediately clear he wasn't overly familiar with what he was talking about. He didn't really seem to have much of a grasp of the chemistry or biology involved, or any real understanding of the epidemiological data. To his credit, he admitted this straight off the bat and told me he had been "tutored" by some folks in the anti-fluoride movement, on whom he was relying on solely for information. I thought it somewhat daft for a politician to place so much stock on the claims of a lobby group for their information, particularly when the medical literature doesn't back it up.

Prior to the debate, I asked him about this, and the more conspiratorial elements of the anti movement. He admitted there were some pretty "out there" people pushing the issue to him but he was trying to ignore them and focus on the concerns of his demograph.  Again, I wish to stress that I do think Brian acted with good, if somewhat self-serving, intentions to represent the voter core he was aiming for. I just should strongly disagree with the idea that the best way to serve your constituents is to cater policy to the most uninformed or outlandish. While I haven't listened to the audio of the debate, from the twitter response Brian's shaky knowledge was evident enough that it discredited him somewhat.

The motion was, by the way, defeated. Thinking that was finally the end of it for another few years (the fluoride conspiracy theory stuff pops up with cyclic tenacity every few years, and has since the 1950s ), I enjoyed the wedding I'd come back for, had a lovely weekend and mainly ignored the nasty comments I got on twitter. But when I came back to work, it became clear I had irked someone...

Pro-tip: If you're going to write a long, rambling letter trying to someone's employer,  at least attempt to get their name and profession correct. "Physicist gets done for medical negligence" would be a first, mind..

Mr Waugh (despite getting my name wrong, and apparently unaware that I am a physicist, not a physician)  had penned a long letter to my employers, asserting a number of things that I was supposed to have said. Some of which he quoted mainly correctly, some out of context and some of which was completely and utterly false. As to why he wrote to my university and not me, I can only hazard guesses. Waugh himself is an appointee to the Sustainable Energy Authority of Ireland since 2012  (as Gerry Byrne's article in the Sunday Times explains, Mr Waugh claims to be director of the SEAI but they do not have such a position and in any case, have clarified Mr Waugh is an ordinary board member) , yet I wouldn't write to the Irish government condemning his factual distortions as this would strike me as pointless and potentially vindictive - Waugh's personal opinions on fluoride are presumably his own views, and he is entitled to them. As to why he he didn't extend me the same courtesy I am unsure. As I take pains to make clear, in my capacity as a science and medicine writer I don't speak for any of the institutions for which I work. In my biographic information, I make clear that I am a physicist, not a physician. These details are important, as it's important for a science writer to be as transparent as possible and to clarify that I am an independent scientist and not someone with a vested interest in a particular narrative. I write because I feel it's important and useful to analyse media issues from a scientific perspective, not because anyone tells me to do so.

To their eternal credit, the university were very supportive,  and reiterated that academics have a right to their own opinion. Even so, it made me apprehensive about writing more on the topic - I am 28 years old, and still a relatively young scientist and while I love communicating science, the last thing I want is to be hounded or have my colleagues and friends hounded, especially for stating something that is, scientifically at least, uncontroversial. I authored other pieces in the interim, on other topics I deemed both more important and less thankless. I tried to avoid fluoride, and its passionate but often scientifically illiterate fan base. I gritted my teeth and did my best to ignore it when politicians made populist noises to appease these campaigners, but it grated on me severely as a number of senators and TDs I had formerly quite liked continued to make populist noises and parrot the the claims of these groups with zero apparent interest in checking this against the scientific literature.

Then, in February this year, the matter arose again when some towns in West Cork decided to pass motions limiting the use of fluoride. This was being hailed as a vindication by the protesting groups, a "proof" fluoride was dangerous. This was of course circular logic and utterly wrong-headed, but more ominously a textbook example of blind scaremongering and political expediency trumping scientific analysis. This is a dangerous chasm to fall into, and so I accepted an invite oto RTE's today with Sean O'Rourke. Of the four speakers, I was the only one in support of the practice and had to refute the laundry list of claims by the speaker prior to me, Owen Boyden. Claims like...

  • Ireland and Singapore are the ONLY countries that fluoridate!!!  - Not even close, and utterly disingenuous. America, Australia, New Zealand, and Canada also add fluoride to their water to name but a few. Other countries in Europe add fluoride to their milk, salt and food. There's also the fact that fluoride in water often occurs naturally as a function of mineral load, so that certain areas will be naturally higher in fluoride than others. The only way anyone can ever drink pure H20 would be to go a chemistry lab and down a glass of de-ionised water. Yet more countries have a dental system with regular fluoride rinses.

  • Fluoride causes cancer etc! - This one boils my blood. It's utter nonsense and designed purely to scaremonger. As I outlined in my IT piece, the National cancer institute in the US have buried this one on numerous occasions yet it crops it all the time, precisely because it is  so scary and emotive that it can effectively paralyse reason. Boyden claimed that thousands of international scientists supported this view - I would wager that if he really thinks that's the case, Boyden has never read an oncology or epidemiology paper in his life.

There were plenty more - I outlined the case for fluoride, and argued that health policy must be rooted in fact, not emotive fiction. You can listen here if you're so inclined. Despite the fact I was the only guest supportive of the practice and outnumbered by others, somehow they still felt hard done by...

Now I'm sponsored by Glaxo-Smith Kline? News to me!

It didn't take long for accusations of conspiracy to surface; Boyden claimed I was sponsored by drug company Glaxo-Smith-Kline. Firstly, as I keep having to point out, I'm a physicist. Unless drug companies now illicitly fund mathematical models on the sly as part of some nefarious scheme, it's a charge that makes no sense. I have no dealings with GSK. In any case, I'm pretty sure GSK have nothing to do with water fluoridation so the conspiracy charge fails on two counts. Whether Boyden actually believes this or just said it to save face is anyone's guess.

The Girl against Fluoride, the chosen moniker of Aisling Fitzgibbon, also took to her facebook page to decry me and add her own conspiracy charge. Bear in mind that Fitzgibbon's main qualification is apparently in the totally-legitimate-and-not-at-all-weird-sounding Angel therapy. She also professes belief in homeopathy and has a background of vaccine opposition. Oh, and her family believe that the pill leads to homosexuality too - Geoff Lillis has written all this up before and it's worth reading his background piece here, and while I don't want to engage in an ad hom argument, much of this might suggest Aisling FitzGibbon is perhaps not the most reliable budding epidemiologist going and maybe has some teensy problems with the scientific method. Rather depressingly this hasn't stopped her getting the ear of several politicians in Ireland.

Pssht. I'm actually funded by the Lizard people. WAKE UP SHEEPLE!

Such charges are tiring and real copy-and-paste jobs: I don't think I've ever (knowingly) defended pharma interests - I have, and will continue, to slam bad science however. I also don't work in materials as a ten second google search would have revealed but why let the truth get in the way of a good narrative? Nor, as I have mentioned before, is this the first time TGAF and her followers has accused me of conspiracy. Last time it was the Rockefeller foundation who were apparently footing my bills I believe, but tomorrow it could be monsanto, or the NWO, or the illuminati, or whoever. The point being is that charges of conspiracy and inconsistent as all hell and meant to distract from valid criticism. Perhaps because the foundations of their argument are so shaky, attacking the messenger is easier than honest introspection and detached analysis that might show their whole raison d'etre is fundamentally misguided. 

In some ways the emotive reaction that this topic triggers is better understood through the lens of psychology - these people have made this narrative part of their world-view. They paint themselves as heroic characters striving against a government policy of control, as brave crusaders. That they might be wrong then fundamentally undermines their world view, and their perception of self. If this is the case, then perhaps they simply cannot deal with the cognitive dissonance that would cause; if they are wrong, then their fundamental self-perception is wrong.

Much of this ties in with the concepts of cognitive dissonance and motivated reasoning - When I or anyone else criticise the claims they make, they view this not like scientists as a useful correction of an error but rather as a fundamental attack on "them", their identity, the narrative they have constructed. This response is particularly unfortunate as it is an insulating bubble where any analysis is paramount to heresy and anyone disagreeing is the enemy. And it is always easier to attack then to reflect candidly - when I read the paper this morning, I found that Cork Fianna Fail councillor Chris O'Sullivan has launched a motion seeking the "immediate cessation of water fluoride" in Cork. Either the counseller is genuinely that ignorant of scientific literature or this is a transparent ploy to win support on a populist issue in a specific area renowned for it's distrust of such interventions - it is no coincidence that West Cork also has the lowest rate of vaccination in Ireland and has been the epicentre of all recent outbreaks of measles.

In an act of appeasement, Minister Simon Coveney has pledged to hold a review into the subject. That's fair enough, but ignores the fact we already have an expert body on fluoridation, and the fact the scientific literature is quite clear on the whole subject. While I have no problems with reviews (and I'd imagine that as usual, fluoride will be given a clean bill of health as it has in independent assessments for decades ) I think it's naive to think this will make the protests groups go away - they have no interest in an independent scientific assessment, as they have already come to their dubious conclusion - No expert body will be trusted unless it agrees with their assertions, and given their entire case is fundamentally flawed, there is no good outcome to this.If the review board find nothing remiss, they'll merely play the conspiracy card, as they have with the IEBF.

The bigger question to me is why are our elected representatives pandering to such tired old claims?  Are we willing to allow health policy to be decided by scaremongering claims rather than solid scientific evidence? Even in an Irish context the benefits of fluoride are clear, with non-fluoridated areas having ~63% more primary cavities than fluoridated areas. This saves much more money than it costs, but more importantly than that it provides a baseline protection for everyone - are we really going to scrap that because of baseless claims rather than sturdy analysis? Are our elected Senators, TDs and counsellers really showing such contempt for science that they're willing to take the lead from pseudoscientists, conspiracy theorists and those fundamentally immune to evidence rather than listen to the expert boards convened on those very topics?

If that is the case it's more only depressing, but it sets a worrying precedent - if scientific expert boards and years of data can be so easily cast aside, this truly is a backwards set. If winning votes and taking popular positions matters more to our elected representatives than sustainable sensible policy, I think they should be called to task for it and forced to defend why they think that is acceptable.

I wish I had a simple answer for how to counter this, but all I can suggest is this; if you are Irish and feel like I do that such a path is a dangerous one to take, then I urge you to write to your representatives and point out that these claims are bogus and the self-appointed experts who have been making the most noise are nothing of the sort. Call them on their lack of basic research, their contempt for science - share the Irish expert body on Fluoride report, or Gerry Byrne's article, or even this - If anyone does contact their TDs and councillors on this, I'd be eager to hear their response and rationale for their actions or inactions.

Again, fluoride is a side-show but one that is so outlandish it needs to be challenged. Allowing these dubious voices dominate the conversation despite their steadfast warping of the evidence has been encouraged by many of our politicians and this is no acceptable.

There are consequences for poorly informed policy and we deserve better from our elected representatives.

UPDATE: Gerry Byrne debated with Declan Waugh on Today with Sean O'Rourke today, and his rebuttal of all of Waugh's claims was simply brilliant. I'll upload the audio as soon as it's available, but sadly I do not think even this car-crash performance from Waugh will deter his followers.[Audio here now!]

Side note - There have been some other figures in politics that have impressed me. Labour Councillors Ronan McManus of Bray and Padraig McLoughlin of Dublin have taken an incredible amount of personal flack for suggesting evidence based policy, and have politely but firmly countered the tide of nonsense. I say this as to make it clear I do not tar all politicians with same brush. On a personal note, I must thank Matthew Carrigan, Anita Byrne and Geoff Lillis for their constant debunking of many of these claims.

Tuesday, March 4, 2014

Tumour spheroids, global warming, homosexuality and motivated reasoning - a somewhat discombobulated research and writing update

 Just a very quick short post of what has been going on lately.. promise you there's a dedicated proper piece on a stand alone subject that should make an appearance later this week...until then, enjoy this somewhat eclectic assortment of subjects

When I logged into write this post, an embarrassing statistic hit me; it's been almost 6 months since I've actually posted something here. I won't insult your intelligence by stating  yet more reasons for my inconsistent posting patterns - my constant flimsy excuses for tardiness transports me back to my teenage days, concocting yet another convoluted excuse for why I had done precisely zero homework, a policy that worked solely because most teachers eventually gave up in exasperation and just stopped asking me.  

Despite the radio-silence here,  I've been relatively productive, juggling irons in a fire whilst mainly avoiding burning my fingers. So in no particular order, a little bit on tumour spheroids, motivated reasoning, climate change denial, self-delusion and the same sex marriage debate! 

(Admittedly that's a slightly jarring combination of topics, but I will endeavour in future to confine each post to a particular topic - stand by later this week for something specific!)

1. Oxygen modelling in multi cellular tumour spheroids 
When I'm not incurring the wrath of the Christan right, the paranoid left, conspiracy theorists, free-market disciples and quackery peddlers I do quite an amount of science. In fact, I even use science as a verb - "I science a lot".  In January we published a paper in Royal Society Interface on oxygen dynamics in tumour spheroids.

So what does this mean? In cancer, oxygen plays an incredibly important role - cancer can be viewed as defective mutant cells dividing utterly out of control, and as a result tumour regions with poor oxygen occur when the cells grow haphazardly. Poorly oxygenated (or hypoxic) tumour regions become far more resistant to both chemotherapy and radiotherapy, and conversely well oxygenated areas respond better. We're interested in modelling how oxygen diffuses through tumour tissue as a "map" of the underlying oxygen distribution would help better inform treatment strategy - essentially, if one had a map of oxygen, then it follows that you could boost dose or treatment to the regions that needed it most.

To model how oxygen diffuses through tumour tissue,  we looked at the simplest possible 3D case, a tumour spheroid - these are "balls" of tumour cells which divide aggressively until they run out of nutrients like oxygen. Picture a tumour spheroid as a clump of cells, growing in a sphere shape with a source of oxygen surrounding it. Oxygen diffuses through the ball, being consumed by the cells. However, at a certain size, all the oxygen is consumed before it reaches the centre most cells, and these cells, starved of oxygen, die out. This leaves a void of dead cells in the centre. The outermost well oxygenated cells are still happily eating oxygen and making clones of themselves, but the inner bunch die off, resulting is something like a hollow ball.

This pretty little thing is actually a stained cross-section of a DLD1 colorectal tumour spheroid - The centre is starved of oxygen or anoxic and the cells here die off. The cells in red are becoming hypoxic and the green ones are still merrily dividing.

In the paper just published, we derive a mathematical model which predicts oxygen level at any point in the spheroid, and explicitly predicts the boundaries of a tumour. This model can then be used to estimate the consumption rate of the tumour cells. Consumption rate is important, as cells which are oxygen hungry will devour diffusing oxygen quickly, resulting in more hypoxia and a thinner "shell" - in essence, consumption rate decides the extent of hypoxia to a large degree. 

Of course, theory is fun but it's important to validate it - we did that by using a series of DLD1 tumour spheroids, which fit the model very well and allowed us to pull out the estimated consumption rate. Spheroids are in some respects a very simple model of cancer as they're divorced from the complicated vasculature (blood supply) of a real human tumour, but the fundamental principle of oxygen diffusion and consumption is the same throughout, so understanding the relationships between consumption and oxygen status is a good first step. 
The whole thing is an interesting combination of physics, mathematics and biology. If you're interested in the detail, the paper is open access and available from Royal Society Interface here

2. Climate change denial and motivated reasoning
Back in October I wrote an unashamedly scathing rebuttal of climate-change denialism for the Irish Times, which is viewable here. The overwhelming scientific consensus is that climate change is real and that we've caused it, yet despite that there are a sizable bulk of politicians, media commenters and irksome people who try to maintain the utterly untenable position that climate change is a myth. Rather than repeat myself, I'll steal from the piece -

"..Such contrarian writers and broadcasters paint themselves as climate “sceptics”, but this is a calculated misnomer. Scepticism is an essential part of scientific endeavour. It demands all claims are treated as unproven until evidence and experience either confirm or falsify them. Denialism, by contrast, is the stubborn and persistent refusal to acknowledge what the evidence shows beyond all reasonable doubt. Evidence for climate change is overwhelming, confirmed by measurement, theory and experiment. Self-proclaimed climate “sceptics” are nothing of the sort; they are rank denialists, deliberately refusing to accept the incontrovertible evidence that their position is untenable."

As expected, the bog-standard climate trolls appeared in the comments and on my twitter feed within hours. Parroting the same pack of tired false buttals and quite literally calling black white; despite having an idealistic thing against blocking, the stream of aggressive nonsense ensured the block button on twitter became my friend. The demographics of the negative responses interested me though; they were all male, politically conservative with strong free-market views. Was there something to this?

Of course, anecdotal evidence is not evidence, so I had a peek at the literature to see if anyone had studied this from a psychological point of view and hey, presto - climate change denial  is associated with a particular set of conservative beliefs and a distaste for any form of regulation. But it isn't solely the preserve of conservatives to deny evidence to fit a pre-existing worldview; liberals can be just as guilty of dismissing solutions like nuclear power based on their own emotional reaction rather than the evidence. This is part of a phenomenon called motivated reasoning, where reality is filtered and selectively taken on board to pacify rather than challenge a preconceived notion.

Festinger explains motivated reasoning - I couldn't find one of that cliche quote things so I made one myself in ten seconds with that bastion of cutting edge photo manipulation Microsoft paint - because quotes with pictures is internet currency!

I penned a Guardian piece on this very subject, arguing that pragmatic decisions have to be made - decisions based not on some dubious worldview but grounded on the available evidence. Perhaps this is wishful thinking, but I am dearly hoping we can collectively get our act together as a species. Am I being too optimistic? Have a gander and tell me yourself!

3. On why our ideological fixations blind us to reality

On the subject of fooling ourselves, I did a little bit for the Irish Times on this very subject back in January, investigating our collective staggering ability to get everything wrong about everything and still think we're good judges of those very things. 

4. Homosexuality, nature and same sex marriage
As the same-sex marriage referendum in Ireland appears on the horizon, the usual suspects (whom we cannot mention because in a neat Orwellian trick,  pointing out people are being homophobic is apparently hate speech now - for context if you don't follow Irish Media see here!)  are out shrieking about how damaging all this is to the "sanctity" of marriage and OH GOOD LORD WON'T SOMEONE THINK OF THE CHILDREN?!

Helen Lovejoy - Iona material
Somewhere in all this sound and fury, the biological fact that homosexuality is perfectly natural has been glossed over by the anti-equality side, and the equally ominous insinuation that gay people are merely morally deviant scallywags who shouldn't raise kids is all too often made. I've poked that hornet's nest before over a certain institute's ramblings (Write up on that fun time here!) but decided it was important to yet again that homosexuality is perfectly normal and is not some strange lifestyle choice for deviants. I This ran in the Irish Times is December and you can take a peek hereEssentially , the take home message is

"Denying homosexuals the rights that are accorded to heterosexuals is not defending marriage or children, it is barefaced discrimination and no amount of oratorical dexterity or false expressions of concern can get over that."

On a side note I cannot help but feel I'd have more respect for that particular organisation if they just came out and said they had a religious ideological problem with homosexuality than their continued attempts to scaremonger the general public into supporting their dubious position. I'd still disagree to the hilt, but it would be far more honest than their current carry on. 

Warning: Some pretty homophobic comments under the tagline.

Right, that's your information overload for now. More focused post coming up soon!

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