First we have to recognize that the term “diagnosis” refers to various types of entities. A diagnosis is a label that we use to describe the signs, symptoms, natural history, and possible biological causes that we observe in more than one patient. There has to be some recurrent pattern, and that is what we are labeling. The term “disease” is similar, but more specific, referring to a specific pathophysiological entity - a specific malfunction or dysfunction of some biological process. For example, myasthenia gravis is a specific disease in which the immune system creates antibodies that attack the acetylcholine receptors on muscle cells, inhibiting muscle contraction and causing weakness and fatigue. In fact MG can be divided into several subtypes, depending on the presence and type of antibodies detected. It is a very specific pathophysiological entity, and diagnosis and treatment flows from our understanding of the disease process.

We do not always understand the details of what causes a specific medical entity, however. Often we start with a syndrome – a constellation of signs, symptoms, and natural history that occurs in more than one patient. It then may take years or decades to sort out the causes or causes of the syndrome, subtypes, prognosis and treatments. Knowledge of the cause is also not black or white. There are layers of depth and detail to our knowledge of various syndromes and diseases. We may know that a disease is an infectious disease, but not know much about the organism. Or we may know what body tissue is being affected and how that results in the symptoms, but not what is causing the damage.

Some labels are what we call a diagnosis of exclusion, but even here there is a range of what we mean by this. A diagnosis of exclusion is what you are left with once all the diagnoses we can rule out have been ruled out. This can be simply a placeholder for our ignorance, and sometimes the name reflects this, such as “fever of unknown origin.” Sometimes it is a “garbage pail diagnosis” – a label we throw into everything we don’t understand but with certain features in common. It think “chronic fatigue syndrome” is a good example of this. CFS is multiple entities that have in common chronic fatigue that is otherwise undiagnosed.

But sometimes a diagnosis of exclusion is a well-established pathophysiological entity, just not one we can practically diagnose with a laboratory study. Migraine headaches, for example, are very well understood (although not completely) pathophysiologically, yet there is no diagnostic test that positively establishes the diagnosis of migraine. It is diagnosed by having a number of typical symptoms and a negative workup for other causes.

With all this in mind – how do we establish that a previously unknown medical entity, such as Morgellons, exists? It’s tricky, but first we need to establish that there is a unique syndrome worthy of its own label. Those who suffer from “Morgellons” have a chronic sense of itching and tingling under their skin. This sensation leads to scratching. The dermatological manifestations include open sores, and there have been reports of strange fibers extruding from these sores. Sufferers also often exhibit psychiatric symptoms, such as anxiety.

There are two schools of thought about what is the true nature of Morgellons. One side, including the Morgellons Research Foundation, advocates the position that “Morgellons disease” is an infectious disease, primarily a skin infection. The infection leads to the itching sensation, the sores, and the strange fibers. The constant irritating sensation also leads secondarily to the psychiatric symptoms. They cite evidence linking Morgellons to Lyme disease, and note that sufferers often respond to prolonged antibiotic use.

The other side believes that the psychiatric symptoms are primary, a form of delusional parasitosis – or the belief that one is infected with parasites. The skin sensation is therefore a somatic (sensory) delusion, leading to chronic itching that causes the skin manifestations. The strange fibers are simply fibers from clothing worked into open sores, and sometimes even healed into healing sores. Analysis of the fibers has shown that they are often consistent with various textiles, and that they are not biological in nature. Any bacteria found in the sores are incidental and not causative, and response to antibiotics is incomplete which is more compatible with a placebo effect than a true antibiotic effect.

The history of Morgellons is relevant as well. The term and the belief that this is a distinct entity did not derive from the observations of physicians or scientists, or any study or new knowledge about biology. It was invented by a mother, Mary Leitao, who believed her son suffered from this entity, and was frustrated that she could not get a doctor to give him a diagnosis she found acceptable.

The presentation of Morgellons is indistinguishable from delusional parasitosis. This does not necessarily mean it does not exist as a separate entity. There are many syndromes in medicine that have more than one disease cause, but share a final common pathway of symptoms. But if we can know that there are distinct diseases under the same syndrome, there must be some evidence we can use to separate them out. With Morgellons there is no convincing evidence of any new or specific feature that distinguishes it as its own disease entity. Proponents make several claims – unidentified fibers and infectious agents mainly, but nothing proven.

This was the focus of the recently published CDC study. They set out to describe and examine those labeled with Morgellons to see if they could find any features that would distinguish Morgellons as a possible distinct pathophysiological entity. In short, their results were negative. The fibers that sufferers often find in the lesions were consistent with fibers from clothes and the environment, mostly cotton. The lesions themselves were consistent with scratching, and did not display any unusual features. No infectious agent was identified. Here are the results from the abstract:

We identified 115 case-patients. The prevalence was 3.65 (95% CI = 2.98, 4.40) cases per 100,000 enrollees. There was no clustering of cases within the 13-county KPNC catchment area (p = .113). Case-patients had a median age of 52 years (range: 17–93) and were primarily female (77%) and Caucasian (77%). Multi-system complaints were common; 70% reported chronic fatigue and 54% rated their overall health as fair or poor with mean Physical Component Scores and Mental Component Scores of 36.63 (SD = 12.9) and 35.45 (SD = 12.89), respectively. Cognitive deficits were detected in 59% of case-patients and 63% had evidence of clinically significant somatic complaints; 50% had drugs detected in hair samples and 78% reported exposure to solvents. Solar elastosis was the most common histopathologic abnormality (51% of biopsies); skin lesions were most consistent with arthropod bites or chronic excoriations. No parasites or mycobacteria were detected. Most materials collected from participants’ skin were composed of cellulose, likely of cotton origin.

Solar elastosis is essentially damage from sun exposure. The biopsies found no features new or unique to Morgellons. Clinical examination also failed to find anything that would imply a new pathophysiological entity. This was a descriptive study only, so there was no therapeutic intervention.

This study, essentially, is a formal and elaborate exercise in the diagnosis of exclusion – but really thoroughly ruling out known diseases or types of disease and also just looking for clues of a specific biological process. Basing conclusions on negative evidence or the absence of findings is always tricky, but not worthless and should not be dismissed. It’s also important to recognize that it is those who are claiming that a new disease exists that bear the burden of proof, and what this study showed is that every line of evidence in the argument that Morgellons exists as a distinct disease does not hold water. The fibers are not biological or mysterious – they are fibers from clothes. The skin lesions are bug bites and scratching (excoriations), and not some strange or suspicious process. There are no biopsy features that suggest a new process, and there is no evidence of an infectious process, an autoimmune process, a toxin, or anything else that was looked for.

There are features that are suggestive of a psychological entity, such as the presence of multiple somatic complaints and coexisting depression. It is always possible that these can be secondary to the illness, rather than the cause of the illness. This comes up in medicine all the time – are the physical symptoms causing anxiety, or is the anxiety causing the physical symptoms? How do we distinguish these two scenarios? Well, first we look for a biological cause of the symptoms. We may even treat for likely or common entities even if we cannot document them. But we also make a judgement based upon the nature of the psychological symptoms – do they seem out of proportion to the physical symptoms? Are the physical symptoms those that can plausibly be caused by a psychological cause?

In the case of Morgellons, we have a known psychological entity (delusional parasitosis) that fits well with the presentations, and now we have a thorough and complete lack of any findings to suggest that something else is going on.

What about response to treatment? This was not part of the study, and would be a good follow up. For example, when we think it is likely that a presentation is caused by a primary underlying anxiety disorder, we can treat the anxiety and see to what extent the physical symptoms resolve or improve. However, somatic disorders can be fairly difficult to treat (more difficult than anxiety or depression, which are not easy themselves). Further, it seems (although I am not aware of any specific studies on this) that the existence of a subculture that promotes the notion of a biological rather than psychological disorder invests sufferers in this conclusion, makes them hostile to a psychological diagnosis, and more resistant to treatment.

The authors of the study recommended that patients with self-diagnosed Morgellons might respond best to psychological treatments. No other specific treatment can be recommended based upon their study. This is not quite the same thing as concluding that Morgellons is a psychological entity. Medicine is an applied science, and we have to make decisions with incomplete information or tentative conclusions. I agree with the authors, who were very cautious throughout the paper, that the totality of evidence strongly suggests that a psychological cause of Morgellons is most likely, and there is no case to be made for any other alternative.

This still leaves open the possibility of an unknown – and believers will grasp onto this possibility. But there is always the possibility in science of a complete unknown. We have to keep this possibility in perspective, however. It is important to emphasize at this point that our knowledge of what is happening in a patient or with a disease is not black or white – we know everything or we know nothing. Even if there is an unknown entity at work, we are fairly good at finding signs that suggest what type of process is going on. We can see that the body is responding to some infection, or is having an inflammatory response, for example. We can rule out categories of disease by showing the absence of signs that should be present.

With this study, in my opinion, the evidence is now fairly solid that Morgellons is not a new pathophysiological entity. It is entirely consistent with delusional parasitosis. There is more than sufficient evidence to treat based upon this conclusion.

Autism is a brain disorder. Neuroscientists are learning more and more about what is different about autistic brains from more typical brains. One feature seems to be reduced communication among neurons in the brain. Autism is diagnosed clinically. It is usually first recognized by the parents, who then bring their child to medical attention and after an evaluation the diagnosis is made. At present there are no supporting laboratory tests – we don’t diagnose autism by an MRI scan, EEG, or blood test. It is diagnosed by clinical observation and some standardized questionnaires and cognitive tests. At the more subtle end of the spectrum the diagnosis may not be made right away, not until the child is a bit older and can be more thoroughly evaluated.

The median age at diagnosis was 4.4 years in 1992. This has steadily decreased, to less than 3.4 years by 2001. This effect is greater in higher socioeconomic status (SES) groups. Low SES children are diagnosed later than higher SES children, and this gap has widened in the last 20 years. There has also been a linear increase in the number of autism diagnoses since 1992, aggregating in birth cohorts, with a greater effect for higher functioning children with autism. This suggests that more diagnoses are being made at the milder end of the autism spectrum, and at a younger age, with a strong social influence.

The current dominant interpretation among experts (I’m not sure it’s robust enough to call it a consensus) is that the increase in autism diagnoses over the last 20 years is due to increased surveillance, widening the definition, diagnosing children at younger ages, and diagnosing milder cases. A number of studies have also looked for signs of autism at younger and younger ages, with several showing differences between children who will go on to be clinically diagnosed on the autism spectrum from other children as early at 6 months of age.

Now another study has been published also demonstrating these results. Researchers looked at infants aged 6-10 months old and showed them pictures of faces with the eyes either looking toward or away from the infant. The researchers recorded brain wave activity with EEG, looking for differences in brain response between these two stimuli. A typical child should respond differently to the two images, as a human face looking toward the infant should evoke more of a response.

They found that there was indeed a difference in brain response between the two stimuli, but in those children who would later be confirmed to have autism the response was generally diminished compared to children who were not later diagnosed (at 36 months). The effect was robust, but not with sufficient sensitivity and specificity to be very useful clinically. This is an important distinction to make. The results were statistically significant, meaning that there is very likely a real effect here.

In other words, even as early as 6 months the brains of children with autism respond differently than children without autism in a way that one might predict from the symptoms of autism (diminished social responsiveness). But there were still false positives and false negatives, limiting such a test’s usefulness when applied to an individual child. The false positives and negatives may be due to the heterogeneity of autism as a spectrum of disorders, or to limitations of the diagnostic technique itself. Probably this technique (in addition to being refined) will have to be combined with other methods of early diagnosis before application to the individual will be practical.

There are several implications of this research worth discussing. The first is that early diagnosis of autism will improve early access to intervention, which seems to make a difference in outcome. Laboratory confirmation can help to reduce doubt or confusion as to the proper diagnosis, and lead more quickly to services for young children. There are also implications for our understanding of autism as a brain disorder. What, exactly, is happening in the brain of children with autism? This study has indirect implications for this question, but still adds to our pathophysiological knowledge of autism as a disorder.

Finally, there are implications from this research regarding the ongoing social (but not scientific) controversy of the role of vaccines and other environmental factors in autism. If the signs of autism are present at 6 months of age, then vaccines that are given after 6 months cannot be implicated as a cause of autism. This unavoidable implication, however, is unlikely to move the anti-vaccine community.

As with any single study, this new study is not definitive. Follow up research is required, and it seems that this technique will likely have to be combined with other techniques to be clinically useful. It adds to existing research, however, increasingly pointing to the detection of differences in the brains of children with autism as early as 6 months of age.

This also fits with the dominant view that autism is likely a complex set of genetic disorders. Environmental factors cannot be entirely ruled out, but genes seem to be playing a dominant role in autism. If this is true it may be theoretically possible to push early detection of autism to even younger ages. Then again, perhaps not – perhaps the brain has to develop to a certain point before the differences in brain function are there. Six months, so far, seems to be the point of earliest detection, and this new study supports that (although they did not study younger children).

It would be interesting to apply these techniques to 2-6 month olds to see if the differences continue to show. In any case – this and other studies like it are pointing the way toward much earlier diagnosis of autism spectrum disorders.

Unfortunately most academics and health care professionals are simply naive to the situation (so-called “shruggies”) and too easily accept these assurances without checking out the facts themselves. Their initial reaction to those of us who are calmly but insistently pointing out that the CAM emperor has no clothes is to assume that we must be overreacting, because CAM can’t truly be as bad as we say. Homeopathy can’t really be made of nothing, can it? But it’s a large industry, with entire hospitals in the UK. How can it be as nonsensical as the skeptics are saying?

This naivete extends, unfortunately, to many university administrators, who are used to being egalitarian and accommodating. Proponents of CAM are sincere, and know how to play the game, so they put their best academic foot forward (often lubricated with grants from ideologically dedicated organizations like the Bravewell collaboration) and work their way into academia. They are persistent, and good at dismissing their critics as closed-minded, unfair, or having an axe to grind.

Perhaps the best tool we have in countering this infiltration of abject nonsense into the halls of academia is to simply point out exactly what they are buying. This strategy has had a great deal of success in the UK, and some limited success in the US. Now, defenders of science and reason in Australia are gearing up for their own fight. A new group called the Friends of Science in Medicine has formed to oppose the watering-down of science in academic medicine and the practice of medicine in Australia. A recent article about the group states:

 A new group called “Friends of Science in Medicine” comprising of more than 350 of Australias top scientists, including basic and clinical scientists, medical practitioners, clinical academics and consumer advocates have formed to address what they consider the “diminishing of the standards applied to the teaching of science in our universities”. The group is concerned about the increased teaching of, what they call, ”pseudoscience” in Australian universities and its application within our health care system.

Their aims are in line with other groups, like the Institute for Science in Medicine (an international group of which I am Chairman). And of course we tackle this issue frequently at Science-Based Medicine.

Our collective strategy is basically two-fold. The first is to establish what the scientific standard should be. The second is to shine light onto the claims and practices of so-called CAM, to expose the fact that they do not meet this standard. Proponents are coy on the first question, and deceptive (either naively self-deceptive or deliberately so) on the second.

We need to affirm the necessity of having a transparent objective scientific standard for medicine. Otherwise, there is no standard of care. There would be no way of determining which treatments were legitimate and which were not. This question has many practical implications – which professions should be licensed, which treatments covered by insurance, which practices allowed under the scope of practice of each profession, what should be taught in medical, nursing, and other health-related curricula, and which practices constitute malpractice. Without a science-based standard, there are no answers to these questions.

That, of course, is what CAM proponents want. How else can you practice homeopathy, get covered for it, have it be included within your scope of practice, and not be sued blind.

Further – we can’t have a double-standard. Within medicine there is a pretty clear consensus as to what the scientific standard is. It is slowly evolving, if anything becoming more stringent as we root out more and more subtle ways of subverting best scientific practice. CAM as a category exists to weaken this standard, or to create a double standard for themselves so that practices that are not science-based can be taught, used, and covered. But (I hope) CAM is starting to be the victim of their own success, in that as they have successfully promoted CAM it is necessarily coming more and more into the light. As it does it is getting easier to expose CAM for the utter nonsense that most of it is.

Groups like those mentioned above are starting to form – comprised of health care professionals who have bothered to look and see what is happening.

A recent study published in PLOS One looked at the small question of what part of the face do people generally look at when trying to recognize an individual? In particular the authors were exploring the question of cultural differences.

Prior research has shown that Westerners tend to look at each eye then the mouth when sizing up another person. This suggests that they are looking at the details of these individual features. Asians, however, generally look at the center of the face, around the nose, perhaps so that they can take in the spacial relationship among the various facial features. These are two different strategies that can be used for facial recognition. This finding raises at least two questions – are these differences genetic or learned, and is there an adaptive reason for them? The research suggests that it is largely learned (Asians who grew up in the West use a combined Western and Asian style of facial recognition.)

The question of adaptation is difficult to study, but the speculation is that it relates to the difference in feature homogeneity. Western societies tend to have more differences in hair and eye color, for example, while Asian societies tend to have more uniform facial features. Asians, therefore, have to rely upon the spacial relationship among the features, rather than the individual features themselves.

The current study used eye tracking software to look at Malaysian Chinese. They found that, like Western born Asians, they employed a mixed strategy of facial recognition, but one unique to them. They tend to look at the eyes and nose more than the mouth. It is thought that this is also a cultural adaptation to the multicultural society of Malaysia.

The main author said of her study:

“We have shown that Malaysian Chinese adopt a unique looking pattern which differed from both Westerners and mainland Chinese. This combination of Eastern and Western looking patterns proved advantageous for Malaysian Chinese to accurately recognise Chinese and Caucasian faces.”

It’s interesting that we would learn what part of the face to focus on in order to optimize facial recognition. It’s not surprising, however, as we have, as I wrote above, a large part of the cortex dedicated to processing facial information. We tend to focus a great deal of our attention on the face, so it makes sense that we would employ a nuanced and adaptive strategy for facial recognition.

Of course this also explains why we tend to see faces everywhere, including in random patterns. We can even see emotion in the non-existent faces of inanimate objects.

In order see exactly why a crank is a crank one needs to have a clear idea of how mainstream science works and why (something that cranks often lack themselves). Science is often portrayed in popular culture in the quaint manner of the lone genius working away in their lab and developing ideas largely on their own. Further, any true advance is met by nothing but scorn from their colleagues and the scientific establishment. This view may have been somewhat relevant in the 19th century and earlier, but rarely has any relevance to modern science.

Science has progressed in most areas to the point that a large body of knowledge needs to be mastered before meaningful contributions are possible. New ideas and information are shared with the community throughout the process of research and discovery, in papers and at meetings, and ideas are criticized and picked over. Each component of a scientific theory needs to be experimentally or observationally established, and there should be good reasons to distinguish one theory from another. Any viable theory needs to at the very least account for existing evidence and should be compatible with well-established theories or facts, or have a compelling explanation for why they aren’t.

By this process a picture of how the world works is slowly being developed, as a community effort, with occasional stars standing above the crowd. The need to convince the existing scientific community that your ideas have merit is very useful – it weeds out ideas that are fatally flawed or just hopelessly nonsensical. In other words – it weeds out cranks. Of course, cranks don’t like this, so they wail against the mainstream.

Like any human institution or endeavor, the process of sifting out the wheat from the chaff is not perfect. Some chaff gets through, and some wheat may be prematurely removed. But science is also self-corrective, and there is always the possibility of correcting for past mistakes. Good ideas in science have a persistent advantage over bad ideas – they actually accord with reality and so the process of experiment and observation should favor them over time.

With all this in mind let’s take a look at the activity of cranks. Wertheim gives a very good description, talking about the main subject of her piece, and “alternative scientist” by the name of Jim Carter.

Carter’s ideas are not taken seriously by the physics mainstream. He does not have a Ph.D. and has never had any of his work published in a scientific journal. He has just a single semester of university education, which was enough to convince him that what was being taught in physics departments was an offense to common sense.
In response, Carter went off and developed his own ideas. Five decades on he has his very own theory of everything, an idiosyncratic alternative to quantum mechanics and general relativity, based on the idea that all matter is composed of doughnut-shaped particles called circlons. Since the 1970s he has articulated his ideas in a series of self-published books, including his magnum opus, The Other Theory of Physics.

So Carter lacks a formal education in physics and cosmology, something he no doubt considers an advantage. His profound arrogance is in evidence by the fact that after one semester of undergraduate study he felt confident in thinking that he was smarter than all working physicists, including luminaries like Albert Einstein and Richard Feynman. He could not wrap his mind around what was being taught as mainstream physics at the time, and rather than concluding that he needed to work harder to understand it, he decided that the problem was not with him but with physics. Physics did not make sense, so he replaced it with his own version.

This casual assumption of both one’s own genius and the idiocy of mainstream scientists is a core feature of the crank. Although it must always be considered that overwhelming arrogance can be a cover for crushing insecurity. In either case, the end result is an extremely childish approach to science. Carter feels he has not only turned over one concept in physics, something that, if true, can establish a career, but rather that he has replaced all of modern physics. He did this working by himself without testing his ideas with others, having his ideas reviewed by the community, or doing any research that could convince the scientific community that his ideas have merit. He did it, in fact, without ever fully studying the ideas he was rejecting. In short, he just made stuff up and then whined about the fact that his ideas were not recognized for the absolute genius that they were. Again, the problem (from his view) must not be with his ideas, but rather with the scientific community. They simply are too closed or to dumb to recognize his genius.

Wertheim goes on to discuss that, now in the age of the internet, cranks around the world have been able to form their own “alternative” community, publish their own journals, and have their own meetings. There is just one requirement in this alternative community – acceptance. All ideas are accepted (there is no chaff, all is wheat), that is except for one. Whatever is accepted by mainstream science is wrong. That is “the one ring” of crank mythology, that brings all crank theories together and in the darkness of their community binds them together. Otherwise they are largely mutually incompatible. Each crank’s “theory of everything” is a notion unto itself, and is mutually exclusive to every other crank’s own theory of everything (unless there is some incidental overlap). So they get together, present their theories without criticism, and all agree that the evil conspiracy of mainstream science must be taken down.  Of course, if any of them got their way and their ideas became accepted, they would instantly become rejected by the rest of the crank community as mainstream physics.

Wertheim strangely makes a leap from the crank community to the notion that modern science is inaccessible to the public. This is strained point, to say the least. The gulf that separates those with formal education in science from those without is not the source of cranks, it is their particular personality as described above. They are the equivalent of the American Idol rejects, those who got through to the judges just so they could make fools of themselves, who, once rejected, proclaim their own vocal genius and the many inadequacies of the judges. But Wertheim thinks that cranks should be taken seriously and not rejected out of hand. She concludes:

While we may not agree with the answers outsiders give, none of us should be sanguine when some of the greatest fruits of science are unavailable to most of humankind.

This is a massive non-sequitur. The concern she raises, however, is legitimate – it just has nothing to do with the crank phenomenon.

On the real issue of science being accessible to the public, this is a complex issue and Wertheim does nothing to explore these complexities. Yes – advanced physics requires advanced mathematics. There is no way around this. Despite the assurances of cranks, mathematics is the language of the universe, and anyone hoping to make real contributions in physics will need to be fluent in this language. Otherwise you might as well study French literature and not learn how to read or speak French and whine about the fact your ideas are not taken seriously by the “priesthood”.

There is a difference, however, in being a working physicist and being a non-scientist who understands the concepts of modern physics (if not the more complex underlying equations). There are many works that popularize science, and physics and cosmology in particular. You can grapple with the strange and beautiful ideas of physics as a lay person, you just can’t check the math for yourself or fiddle with the equations. If you want to do that – learn the math.

Perhaps that is another feature of the crank worth pointing out. There is a great deal of popular works for the non-scientist to satisfy their curiosity about modern science and to understand the ideas, findings, process, and controversies of modern science. But the non-scientist has to be content sitting in the bleachers as a spectator. Cranks are not content to be spectators. They want to be in the game, but they don’t want to learn to rules, or earn their way onto a team through work and talent. They want to change the rules to suit themselves.

Recently on the SGU we talked about randomness, a concept that can use more exploration than we had time for on the show. The term “random” has a colloquial use – it is often used to mean a non-sequitur, or something that is out of context. It is also used colloquially in the mathematical sense, as a sequence or arrangement that does not have any apparent or actual pattern. However, people have a  generally poor naive sense about what is random, mathematically speaking.

There are at least two specific technical definitions of the term random I want to discuss. The first is mathematical randomness. Here there is a specific operational definition; a random sequence of numbers is one in which every digit has a statistically equal chance of occurring at any position. That’s pretty straightforward. This operation can be applied to many sequences to see if they conform to a statistically random sequence. Gambling is one such application. The sequence of numbers that come up at the roulette table, for example, should be mathematically random. No one number should come up more often than any other (over a sufficiently large sample size), and there should be no pattern to the sequence. Every number should have an equal chance of appearing at any time. Otherwise players would be able to take advantage of the non-randomness to increased their odds of winning.

Computer simulations are another area where a truly random sequence of numbers is valuable.  Random numbers may provide the input necessary for the simulation to run.

It is very difficult (perhaps impossible) for a person to generate a truly random sequence of numbers from their brain. Here are three sequences of numbers, try to find the one that is mathematically random:

0 4 4 7 2 0 6 0 2 3 8 9 9 3 0 2 0 5 3 3 8 6 8 4 9 3 3 8 9 2 4 2 2 1 3 6 4 7 9 7 4 0 2 4 9 9 3 4 5 0

9 4 8 5 7 6 0 9 4 7 3 6 5 2 9 1 7 3 5 7 8 5 4 8 0 2 9 3 8 7 5 1 0 2 5 2 3 5 5 5 0 2 9 8 9 7 7 2 0 3

8 5 5 7 0 3 0 9 2 9 9 2 8 4 7 5 6 6 2 0 3 9 4 8 7 5 0 3 0 9 4 8 7 5 0 3 0 3 8 4 7 5 9 8 7 7 0 3 9 8

The top sequence was generated by a random number generator, the bottom two I produced by typing chaotically (I won’t say “randomly”) on my number pad. The top sequence is statistically random, while the bottom two are not. It’s hard to tell the difference just by looking. Also we tend to underestimate the clumpiness of randomness (called the clustering effect). So, for example, in a mathematically random sequence of numbers, the same digit should occur twice in a row with a certain frequency, and even three, four, five or more times in a row. But such clusters make the sequence look naively non-random.

The top number is what is called pseudo-random. As I said, random numbers are very useful to computer programmers. There are a number of operations that can generate mathematically random number sequences. But they are not truly random because the operation will generate the same sequence of numbers given the same input or seed. There therefore needs to be some way to create a random seed, which can be based upon some physically noisy process, or the time, or something else that changes regularly.

Another example of a pseudo-random sequence is pi. The number pi (3.1415926535897932384626433832795028841971693993751058209 7494459230781640628620899862803482534211706798214808651…) is a statistically random sequence of digits, but of course it is not truly random because it is one specific sequence.

This brings us to the second technical definition of random – true physical randomness. I can throw dice to generate a statistically random sequence of numbers, assuming the dice are fair and I am sufficiently “randomizing” each throw. But from a physical point of view, the result of each throw is not random, but determined by the laws of physics. The number that results on the die must occur given all the physical parameters of the throw. Once the die is cast, the number that will result is determined and not random. In this sense “random” also means “unpredictable.”

The only truly random physical system known to science results from quantum effects. Certain quantum properties are undetermined and unpredictable – they are truly random. In fact, researchers last year developed a random number generator based upon quantum properties – the first truly random number generator.

As with many concepts in science and elsewhere, even seemingly basic or simple concepts can become very detailed and complex when explored deeply. That is one lesson I have thoroughly learned from studying and teaching science  - it’s always more complicated than it seems. In fact, it’s always more complicated than your current understanding. The above discussion of randomness is a quick overview, but there are layers of complexity and detail I did not get into. There are also limits to our current understanding – the universe is more complicated than we know.

It is very helpful, however, to at least understand that there is likely more depth to an issue than one’s current knowledge. But we can still use terms and concepts that are accurate and precise as far as they go, even if there is always a deeper complexity.

This resonated with me, and brought into sharp focus what has bothered me about many encounters I have had in which someone was chiding me for not being skeptical enough. Sometimes this was coming from a perspective that I would now consider denialism, the specific denial of a generally accepted scientific or historical fact for ideological reasons. At other times the cynical pseudoskepticism was really just paranoid conspiracy mongering. For example, I recently received the following e-mail:

I sort of lost interest in you folks way back when OBL was “killed’” and his body disposed of at sea and photographs withheld, all inviting skepticism but instead skeptics earning nothing but ridicule from your team. I decided you weren’t really skeptical enough about some things, just others. Something about the behavior of otherwise excellent minds in the shadow of a powerful military state with an excellent propaganda apparatus. Except that in this case the propaganda was clumsy, the lies flagrant and out there to see …

The e-mailer is referring to our discussion on the SGU of the killing of Osama bin Laden by US forces. At the time we received many e-mails from those who thought we should taken a more “skeptical” perspective – the position that the US government was lying about the killing of OBL to some extent, and perhaps even entirely. Skepticism regarding the government is a typical context for this sort of response.

This can serve as an excellent example, in my opinion, of the difference between true skepticism and the cheap imitation – cynicism.

My approach to such questions is this: Yes, governments lie and cover up their activities. This includes even open democratic governments, like the US. Covering up information can be put into two general categories. The first is legitimate secrecy. The government is very open about the fact that some information is “top secret” and kept from the public for the purpose of national security. There is, however, an internal process by which such information can be assessed by our elected representatives. No one doubts the existence of legitimate secrecy in the government.

The other category of secrecy is illegal secrecy by individuals or groups of people in the government who are trying to cover up their own crimes or mistakes, or perhaps even mean well (they think they are doing what’s right for the country) but are going outside the system. This too, of course, happens. The Iran-Contra affair seems to be an example of this. The public takes for granted that some of this goes on all the time, at least in the form of spinning events or trying to bury inconvenient information without technically breaking the law. We accept a certain amount of this as “politics” – just don’t get caught crossing the line.

The real question is this: is there a third category, of organized deception and propaganda that is extra-democratic but representing the real way that our government operates, not the aberration of individuals? The e-mailer seems to think that the US government is a “powerful military state with an excellent propaganda apparatus.” This does not reflect reality as I understand it. Our government is deliberately not monolithic. There are different branches with a balance of power. There is also a two-party system, with the parties being in strong opposition politically, each more than willing to expose the shenanigans of the other party. And we have a constitutionally guaranteed free press, which may not always be optimally effective, but collectively it works pretty diligently to expose any government lies.

The OBL killing was an interesting event. The government acted partly out of legitimate military secrecy to carry out the operation. Then there was the question of PR – how to handle the aftermath of taking out a figure like OBL. There were many concerns – proving that he was actually killed, but minimizing the making of a martyr out of him, and not wanting to have any remains to act as a shrine or rallying point. I don’t think the government pulled it off optimally. They left far too much room for conspiracy mongering. But I can at least understand their dilemma.

With regard to this event the cynic assumes the government is lying, and assumes they have nefarious purposes and unlimited ability to carry out their deception. But at the same time they are “clumsy” and stupid, so that anyone can see that they are lying. This is conspiracy mongering, not skepticism.

The e-mailer continues:

“I haven’t been listening since much, and so wondered if your skeptical eyebrows raised a detectable scintilla or so when the elite Navy Sal (sic) Team that killed OBL perished in a helicopter crash.”

The conspiracy theorizing cynic sees this event as confirmation that there is a government cover-up. There is no evidence offered for a conspiracy – just take an event and cast it in as sinister and cynical a light as possible, and criticize any who do not follow you down this rabbit hole of not being skeptical.

The Navy Seals have been busy in Iraq and Afghanistan, and it is tragic but not surprising that they are suffering casualties. We don’t need a conspiracy theory to explain this. Further, while members of Navy Seal team 6, the team that killed OBL, were on the helicopter, the US government told the AP that none of them were the individuals involved in the OBL operation. Of course, this could just be another government lie.

I am open to any reasonable interpretation of events and to actual evidence that a specific interpretation is correct. The skeptical point of view is not to just assume the maximally cynical point of view. The skeptical approach is to evaluate the evidence and the plausibility of various hypotheses.

But as Joe said – you can always try to seem more skeptical than the next guy by short circuiting this process and just being cynical.

In Australia recently an ABC program aired that was highly critical of CAM, and now CAM advocates are firing back. The latest exchange was initiated by a group of 34 Australian physicians who are campaigning against pseudoscience in medicine. This is something that should not be controversial, but amazingly there is a large number of practitioners (although a minority) that stand  up to defend pseudoscience in medicine. They report:

Emeritus Professor of Medicine at the University of New South Wales John Dwyer says some courses previously offered at Southern Cross were more “magic” than science.
“We were off to a bad start with Southern Cross University when their founding Professor of Health and Nursing was teaching for years Healing Touch therapy; quite extraordinary nonsense.”

Good for him and his colleagues – we need more professionals who are not afraid to point out that the CAM emperor has no clothes.

Defending nonsense we have:

Professor Iain Graham from Southern Cross University’s School of Health yesterday defended his university, saying the use of alternative therapies, such as homeopathy, can be traced as far back as ancient Greece.

The Argument from Antiquity

I have to give the standard caveat that professor Graham may have been misquoted or misrepresented, but he was quoted making the same argument in a different piece as well. Taken at face value, we have a misstatement of fact combined with a logical fallacy. He probably (if I am being generous) did not mean to state that homeopathy can be traced back to ancient Greece, just that some CAM therapies can. Homeopathy was invented by Samuel Hahnemann about 200 years ago.

But I wonder what CAM modalities he had in mind. Chiropractic? About 100 years. Therapeutic touch? A few decades. Acupuncture is a complex question, but what passes for acupuncture today is less than 100 years old. Perhaps he was thinking about blood letting or trepanation.

It is true, however, that some basic concepts, like the notion of a life energy, can trace it roots to ancient Greece, and other ancient cultures. However, such notions are pre-scientific nonsense. Scientists abandoned the notion of life energy over a century ago because there is no evidence that such a force exists (and there still isn’t) and after figuring out all the basic processes of life there was essentially nothing left for the alleged life force to do.

For some reason, however, professor Graham believes that antiquity in science is a virtue – the “argument from antiquity” logical fallacy. The unstated assumption is that if an idea has survived for hundreds or thousands of years it must be legitimate. This is demonstrably false. Galenic medicine (blood letting, purging, etc. based on the notion of the four humours) survived for thousands of years, and yet it was based on complete an utter primitive nonsense. In fact its tendrils still exists – there is still blood letting, cupping (which is just another form of blood letting) and similar practices going on in the world. It was replaced in the West because of the advent of science in medicine – a trend that Graham apparently wants to reverse.

The Argument from Popularity

Graham’s second swing and a miss is this:

“Eighty per cent of Australians seek alternative therapies,” Prof Graham said.

“Obviously orthodox medicine is not working for everyone,” he said.

I highly doubt that the 80% figure is correct. Most such figures are highly inflated by including all sorts of practices in the CAM category, like exercise, eating organic food, and sometimes prayer is included. US surveys show the percentage of CAM use is around 1/3, but this is mostly things like massage and chiropractic manipulations. Homeopathy is around 3-4%, and acupuncture 6-7%. In fact, only manipulation and massage were in the double digits.

This is all marketing deception – create a false category (CAM), pad it out with commonly used methods, and then claim that the extreme fringes are therefore getting more popular. I don’t know how Graham got to 80% (I doubt such methods are that much more popular in Australia) but it is close to one survey from 2007 that found that 69% of Australians used one of the 17 most popular forms of CAM in the last year. However, they included in their list: martial arts, yoga, massage, meditation, and taking multivitamins. I am not sure what taking multivitamins says about the popularity of homeopathy, but apparently professor Graham thinks that is significant.

In any case – I will grant that CAM as a marketing concept has been somewhat successful, and even that it has gained popularity recently (although not as much as advocates would have you think). That is entirely irrelevant, however, to the question of whether or not any particular CAM modality is science-based and appropriate for a university curriculum (the question at hand).

Universities are supposed to be thought-leaders, to have intellectual standards that rise above the mere notion of popularity. They are supposed to uphold academic standards of scholarship, and in scientific disciplines of high standards in science. It is therefore very odd and disturbing to defend a university policy based upon popularity. Should we allow surveys of public opinion to determine whether or not we teach creationism or astrology in our universities?

Conclusion

These same two arguments keep coming up in the defense of CAM, despite the fact that they are factually dubious and logically fallacious. That, however, is the nature of CAM – it is an intellectually dubious enterprise. We need more professionals like John Dwyer who are not afraid to say so.

In the comments to the above article another very common CAM canard was presented. Commenter “shotinfo” wrote:

According to articles published in both the British Medical Journal and the New England Journal of Medicine, between 85% and 90% of all mainstream medical drugs and procedures have never been scientifically proven to either work or be effective.

I love the fake references – of course no such articles in BMJ or NEJM exist, and no references were offered, but it certainly makes the fake factoid sound legitimate. I have already discussed this issue in detail. The bottom line is that surveys of medical practice find that about 78% of them are reasonably evidence-based. Yet again we have a factual misstatement used to support a logical fallacy (tu quoque). All medical practice should strive to be more science and evidence-based. Pointing out the deficiencies in one discipline does not justify deficiencies in another.

The commenter, however, also misses the real point of criticism of CAM. Mainstream medicine is based upon a culture and institution of science, and a science-based standard of care. The execution of this standard is flawed, but the principle is clear. CAM is not based on a science-based standard. It, in fact, seeks to subvert and even remove the science-based standard of care. And CAM proponents live in a culture of pseudoscience, not legitimate science.

We need to keep pointing this out – and the defenders of CAM will keep making our point for us by quoting the same factual errors and logical fallacies over and over again.

It is ironic that the greatest barrier to the effectiveness of the vaccine program is public acceptance. Part of the problem is that very high acceptance is needed in order to achieve what is called “herd immunity” – where there is sufficient protection in the population that an infected individual will likely not cause an outbreak.

In the US the numbers are pretty good, and have remained so even through the recent increase in the anti-vaccine movement. About 68% of children complete the full routine vaccination series. Many of the individual vaccines have compliance rates in the 90s (MMR, for example, was 92.1% in 2008). The level required for herd immunity varies, but it is generally around 85-90%.

Acceptance of the flu vaccine in the US is much lower. Last year the cumulative flu vaccine use in the >6 month old population was 43%. Many people feel that the flu vaccine is not necessary, that it doesn’t work, or even that it is not safe. Uptake is slowly increasing – we  are at slightly higher levels this year compared to last year, but there is still a long way to go. The flu vaccine does have the added challenge of matching the strains covered in the vaccine to the circulating strains, so efficacy does vary from year to year, averaging about 50% effective. This year, so far, it seems that the match is a good one. We are nowhere near herd immunity levels with the flu vaccine.

Increasingly parents are opting for alternative vaccine schedule - 13% according to a recent survey.  And yet, there is no evidence that any of these alternate schedules is any safer than the standard schedule, but they are less effective – they leave children vulnerable for longer to vaccine-preventable diseases. Use of an alternate vaccine schedule, in my opinion, represents a fundamental mistrust of the medical system. The vaccine schedule is not arbitrary. It is based upon a careful review of evidence, matching the timing of each vaccine to when it is needed and when the child’s immune system is mature enough to handle it. The need for booster shots is determined by measuring antibody levels in response to vaccination. All this evidence is reviewed by panels of experts to determine the optimal schedule.

In place of this system 13% of parents would rather substitute either their own judgment or “Dr. Bob’s Alternative Vaccine Schedule.” They apparently buy into the notion that some lone maverick is better able to parse the research than panels of experts.

The historical relationship between vaccine implementation and the reduction of specific infectious diseases is very clear (which does not stop the anti-vaccinationists from denying it). Further, as pockets of vaccine denial are becoming more common, so is the recurrence of vaccine-preventable diseases. Right now Europe is in the midst of a measles outbreak, with more than 26,000 cases, 9 deaths, and 7,288 hospitalizations so far this year. MMR (measles, mumps, rubella) vaccine uptake is lower in Europe than the US. They are also dealing with many immigrant populations with lower levels of vaccine use, so it’s not all vaccine refusal.

This raises another issue with vaccine use – they are very cost effective. In case you haven’t noticed, we are in the middle of a growing health care cost crisis. The cost of health care is a complex issue I cannot get into here – but what is clear is that vaccines are extremely cost effective. In some cases they may even be cost saving – the cost of vaccine is lower than the health costs of hospitalizations they prevent.

Outbreaks of vaccine-preventable diseases are also occurring in the US. Recently there has been an outbreak of whooping cough on Long Island, for example. Whooping cough is a potentially serious illness, especially in infants. Infants are vulnerable until they are old enough to get the vaccine themselves and so depend upon herd immunity.

Often anti-vaxers point out that when such outbreaks occur it is common for most infected individuals to be among the vaccinated. They imply that vaccines therefore do not work. This is also the case with the whooping cough outbreak. This is an abuse of statistics, however.

What is important is the risk of getting the disease in the vaccinated vs unvaccinated populations. With > 90% of the population getting the vaccine the vaccinated population is much larger than the unvaccinated population. Being vaccinated greatly reduces the risk of getting the disease. Also, if someone gets the disease despite being vaccinated they are likely to have a much milder course.

It also should be noted that while overall vaccine rates are high, there are pockets of low compliance (and these are locations where outbreaks are sometimes occurring).

Anti-vaxers often cite the parents’ right to “informed consent” concerning vaccines. I agree – parents should be fully aware of the risks and benefits of vaccines. When informed with accurate information (as opposed to the misinformation from anti-vaxers) the decision to vaccinate should be an easy one.

The goal, however, is not to really sue but to threaten the blogger into silence. It is intellectual thuggery, meant to defend a charlatan who cannot defend themselves with science and evidence.

However, it is not accurate to describe bloggers who expose charlatans as “lone” – they are part of an informal web of science and skeptical bloggers who are all trying to expose fraud and pseudoscience. When one of us is threatened we have banded together to create what is knows as the Streisand effect – try to silence one blogger and a hundred voices will rise up, having the exact opposite effect that you intend.

Recently a person calling himself Marc Stephens wrote a very threatening letter to Andy Lewis who wrote a critical post about the cancer clinic of Stanislaw Burzynski called The False Hope of the Burzynki Clinic. Stephens tried to make the letter sound legal and official, even though he does not appear to be a lawyer. The letter says, in part:

Please be advised that my clients consider the content of your posting to be legally actionable under numerous legal causes of action, including but not limited to: defamation Libel, defamation per se, and tortious interference with business contracts and business relationships. The information you assert in your article is factually incorrect, and posted with either actual knowledge, or reckless disregard for its falsity.

In other words – the blog post is libel and we will sue if you don’t take it down immediately. Lewis essentially responded the way General Anthony Clement McAuliff responded when asked to surrender by the Germans in World War II – “Nuts.” The post is still up, and now there are dozens of other blog posts up also criticizing the Burzynski clinic and their attempt at silencing criticism.

Legitimate medical clinics use validated and accepted treatment methods. It is therefore always a huge red flag when a clinic offers a “unique” treatment. If the treatment works, why isn’t everyone using it? If it is experimental, then they should be following proper experimental protocol, and the treatment should be entirely free.

Dubious quack clinics, however, make clinical claims for treatments that are not based upon rigorous published double-blind placebo controlled trials that demonstrate safety and efficacy. They often just invent their treatments out of whole cloth, and make implausible hand-waving explanations for how and why they work. They typically offer anecdotal evidence only to substantiate their claims. Sometimes they may try to justify their treatments by cherry picking some basic science studies that superficially may seem to support some aspect of their claims, but they extrapolate and speculate wildly from this preliminary evidence. Some even try to claim that they have studied their treatments, but at best they offer uncontrolled case series, which are of little more value than anecdotes.

Such clinics are allowed to practice because of lax or ineffective regulations. Sometimes they hide in low-regulation zones, such as across the border in Mexico. The Burzynki clinic, however, has been able to continue to practice their dubious medicine in Texas. Often such clinics do run afoul of the law, but this is often just a nuisance; the cost of doing business. The Burzynski clinic was put on trial for cancer fraud, but the result was a hung jury.

Lewis tells this story, as well as the fact that the state of Texas is putting Burzynski on trial to take away his medical license. In response those patients who believe in him are engaged in a letter writing campaign to governor Rick Perry. This is also a common ploy. Quack cancer clinics often have those patients who believe fervently in them. If you treat enough people, some will survive and credit the guru for their survival (even though they may have also received standard therapy). Of course, those who die are not heard from. Heartfelt testimony from true-believing patients is the shield that charlatans use to defend themselves from legitimate regulatory action.

What about the treatment itself? Burzynski claims that he has discovered “antineoplastons,” which can be extracted from a patient’s own urine. These molecules then target cancer cells while leaving healthy cells alone. There is, however, no credible science behind these claims. Burzynski has published studies of his therapy, but they are small uncontrolled case series. He has been promoting his therapy for more than three decades – why is he still doing preliminary research (the last of which was published in 2006)?

Well, that is how he skirts regulation. He offers his antineoplaston therapy as an experimental protocol. However, he still charges huge sums of money for the privilege of being a subject in his “research.” Lewis tells the story of young Billie Bainbridge, who has brain cancer, and whose family is trying to raise £200,000 to send Billie to the Burzynski clinic for “experimental” treatment. I honestly don’t know how he gets away with such flagrantly unethical behavior.

Burzynski’s results have not been replicated by other researchers, and the cancer research community does not seem interested in his work. This is not because of any conspiracy – they just recognize crap when they see it. It is also extremely unusual (for legitimate research) that three decades on he is still fooling around with preliminary studies. It’s almost as if he is just going through the motions of research so that he can continue to charge large amounts of money to desperate patients so that they can get his “experimental” treatment.

Burzynski’s claims are not credible. His behavior is very atypical, and in my opinion is unethical, with all the red flags for cancer quackery. Potential patients and their families should be aware of these facts and be very suspicious of the Burzynski clinic. Meanwhile we will wait to see how the state of Texas responds to this controversy.

As for the threats against Quackometer – well, Burzynski is about to learn that the science blogosphere is a many-headed hydra, and he has just been bitten.