Tag Archives: Healthcare

Storm brews over forced circumcision in Uganda

open quoteThe Ugandan town of Mbale was brought to a standstill on Tuesday afternoon, as a naked man ran through the streets, with more than 50 men in pursuit. He was fleeing a forced circumcision.

Deo survived the forced circumcision after guards at the administrator’s office were able to disperse his assailants, but that was not before other men had fallen victim to the enforced surgical operation.

More than 40 men of various ages have been subjected to the cut in the last two days, as the town goes through a general circumcision programme, but this has faced widespread protests.

Mbale is mainly inhabited by the Bamasaba tribe, which prescribes circumcision to all males from the age of 15, and those who do not undergo the cut are forcefully circumcised.

However, it has emerged that the 40 men who were forcefully circumcised are not of the Bamasaba tribe, but rather were forced to undergo the operation, as they either had Bamasaba wives or girlfriends.

“Since they sleep with our sisters and daughters, we felt they had to be circumcised like the rest of us,” Gerald Wambedde, an advocate of forced circumcisions, said.

The leader of the exercise, Badru Wasike said the circumcision exercise was both a cultural and health exercise.

“We are helping those who feared getting circumcised through cultural processes. We are aware that circumcised men do not easily get infected with HIV/Aids. Since they love our relatives we want them to be safe,” he explained.close quote (Read more)

The Shocking Bullshit behind the “Circumcision prevents AIDS” lie

open quoteA handful of circumcision advocates have recently begun haranguing the global health community to adopt widespread foreskin-removal as a way to fight AIDS. Their recommendations follow the publication of three [1] randomized controlled clinical trials (RCCTs) conducted in Africa between 2005 and 2007.

These studies have generated a lot of media attention. In part this is because they supposedly show that circumcision reduces HIV transmission by a whopping 60%, a figure that wins the prize for “most misleading possible statistic” as we’ll see in a minute. Yet as one editorial [2] concluded: “The proven efficacy of MC [male circumcision] and its high cost-effectiveness in the face of a persistent heterosexual HIV epidemic argues overwhelmingly for its immediate and rapid adoption.”

Well, hold your horses. The “randomized controlled clinical trials” upon which these recommendations are based (I use scare quotes deliberately) represent bad science at its most dangerous: we are talking about poorly conducted experiments with dubious results presented in an outrageously misleading fashion. These data are then harnessed to support public health recommendations on a massive scale whose implementation would almost certainly have the opposite of the claimed effect, with fatal consequences. As Gregory Boyle and George Hill explain in their exhaustive analysis of the RCCTs:

While the “gold standard” for medical trials is the randomised, double-blind, placebo-controlled trial, the African trials suffered [a number of serious problems] including problematic randomisation and selection bias, inadequate blinding, lack of placebo-control (male circumcision could not be concealed), inadequate equipoise, experimenter bias, attrition (673 drop-outs in female-to-male trials), not investigating male circumcision as a vector for HIV transmission, not investigating non-sexual HIV transmission, as well as lead-time bias, supportive bias (circumcised men received additional counselling sessions), participant expectation bias, and time-out discrepancy (restraint from sexual activity only by circumcised men).

That’s a whole laundry list of issues, so let me highlight a few of the more egregious. First, consider the “lack of placebo control.” What does that mean? Normally, when you’re trying to determine whether some medical intervention has a disease-fighting effect specific to its own (hypothesized) mechanisms—and over and above the placebo baseline—you have to have a control group. That group gets a dummy intervention, and nobody is supposed to know which participants were exposed to the actual treatment until after the results are in.

After all, if someone knows (or thinks) that they’re getting a great big helping of medicine, they might act in various ways—whether consciously or unconsciously—that have the effect of generating positive health outcomes but which have nothing to do with the intervention itself. In the case of circumcision, however, there’s no way not to know if you’ve received the “medicine”—you have to go through a whole surgery and then you don’t have a foreskin anymore—so this basic condition of a true clinical trial is violated in the first instance.

But that’s just the tip of the iceberg. As Boyle and Hill point out, the men who were circumcised got additional counseling about safe sex practices compared to the control group, and then they had to refrain from having sex altogether for the simple reason that their lacerated penises had to be wrapped in bandages until their wounds healed – leading to what Boyle and Hill refer to as “time-out discrepancy” in the quote above. By contrast, the non-circumcised men got to keep having sex during the full two month period during which the treatment group was in recovery mode.[emphasis added] Then, mystery of mysteries, the trials were stopped early. These issues pose serious problems for the scientific credibility of the studies. Taken together with the other flaws, here is why:

Let’s assume for a second that the circumcised men really did end up getting infected with HIV at a lower rate than the control-group men who were left intact—even though, as we will see in a moment, we have very little reason to believe that this is so. Why might that outcome have happened?

If you answered, “Because those men knew they were in the treatment group in the first place, had less sex over the duration of the study (because they had bandaged, wounded penises for much of it), and had safer sex when they had it (because they received free condoms and special counseling from the doctors), thereby reducing their overall exposure to HIV compared to the control group by a wide margin” then you are on the right track.

Step 2. How not to report results

Now why should we doubt that the circumcised men actually did have a lower rate of HIV infections in the first place, poor experiment design notwithstanding, as I suggested in the paragraph above? After all, the 60% figure that’s being thrown around in media reports is a pretty big number, and it can’t be off by that much, even if the studies had some flaws, right? Not so fast. Do you know what the “60%” statistic is actually referring to? Boyle and Hill explain:

What does the frequently cited “60% relative reduction” in HIV infections actually mean? Across all three female-to-male trials, of the 5,411 men subjected to male circumcision, 64 (1.18%) became HIV-positive. Among the 5,497 controls, 137 (2.49%) became HIV-positive, so the absolute decrease in HIV infection was only 1.31%.

That’s right: 60% is the relative reduction in infection rates, comparing two vanishingly small percentages: a clever bit of arithmetic that generates a big-seeming number, yet one which wildly misrepresents the results of the study. The absolute decrease in HIV infection between the treatment and control groups in these experiments was a mere 1.31%, which can hardly be considered clinically significant, especially given the numerous confounds that the studies failed to rule out.

Step 3. How not to make public health recommendations

So far we have been discussing problems with the experiments themselves—what’s called “internal validity” in technical terms. I really want you to read the Boyle and Hill paper here, because they go into painstaking detail about each of a long parade of flaws I can’t hope to cover in one blog post. I mean, there are a lot of flaws. Please read the paper. But let’s switch gears now and talk about the flip-side of things, or what’s called “external validity” – that is, problems with taking what you’ve (supposedly) found in a (relatively) controlled setting like an experiment and applying it to the chaotic mess that is the real world.

Lawrence Green and his colleagues published an important article on just this topic as it relates to “the circumcision solution” in the American Journal of Preventative Medicine. “Effectiveness in real-world settings,” they sensibly point out, “rarely achieves the efficacy levels found in controlled trials, making predictions of subsequent cost-effectiveness and population-health benefits less reliable.”

Some major issues with trying to roll-out circumcision in particular include the fact that the RCCT participants—who were not representative of the general population to begin with—had (1) continuous counseling and yearlong medical care, as well as (2) frequent monitoring for infection, and (3) surgeries performed in highly sanitary conditions by trained, Western doctors. All of which would be unlikely to replicate at a larger scale in the parts of the world suffering from the worst of the AIDS epidemic. And of course, circumcisions carried out in un-sanitary conditions (that is, the precise conditions that are likelier to hold in those very places) carry a huge risk of transmitting HIV at the interface of open wounds and dirty surgical instruments. So this is a serious point.

What should we conclude? Green et al. get it right: “Before circumcising millions of men in regions with high prevalences of HIV infection, it is important to consider alternatives. A comparison of male circumcision to condom use concluded that supplying free condoms is 95 times more cost effective.”

. . . .

Step 4. This is serious business

The worst part about all of this is not just that the science behind “the circumcision solution” is so shaky, but that the actual implementation of these recommendations—so vociferously pushed-for by the circumcision advocates doing this research — would very likely lead to more HIV infections, not less. The big idea here is “risk compensation” – the subject of an excellent paper by Robert Van Howe and Michelle Storms.

Risk compensation occurs when people believe they have been provided additional protection (wearing safety belts) [such that] they will engage in higher risk behavior (driving faster). As a consequence of the increase in higher risk behavior, the number of targeted events (traffic fatalities) either remains unchanged or [actually] increases.

They argue:

Risk compensation will accompany the circumcision solution in Africa. Circumcision has been promoted as a natural condom, and African men have reported having undergone circumcision in order not to have to continually use condoms. Such a message has been adopted by public health researchers. A recent South African study assessing determinants of demand for circumcision listed “It means that men don’t have [to] use a condom” as a circumcision advantage in the materials they presented to the men they surveyed. [Yet] if circumcision results in lower condom use, the number of HIV infections will increase. [Citations can be found in the original paper.]

In Uganda, as Boyle and Hill uncovered, the Kampala Monitor reported men as saying, “I have heard that if you get circumcised, you cannot catch HIV/AIDS. I don’t have to use a condom.” Commenting on this problem, a Brazilian Health Ministry official stated: “[T]he WHO [World Health Organization] and UN HIV/AIDS program … gives a message of false protection because men might think that being circumcised means that they can have sex without condoms without any risk, which is untrue.”

. . . .

The studies we’ve looked at, claiming to show a benefit of circumcision in reducing transmission of HIV, are paragons of bad design and poor execution; and any real-world roll-out of their procedures would be very difficult to achieve safely and effectively. The likeliest outcome is that HIV infections would actually increase—both through the circumcision surgeries themselves performed in unsanitary conditions, and through the mechanism of risk compensation and other complicating factors of real life. The “circumcision solution” is no solution at all. It is a waste of resources and a potentially fatal threat to public health.close quote (Read more)

Me on Obamacare

The creation of the AMA was supposed so ensure quality healthcare for everyone. The creating of the FDA was supposed to ensure quality healthcare for everyone. The HMO act was supposed to ensure quality healthcare for everyone. Medicare was supposed to ensure quality healthcare for everyone. Medicaid was supposed to ensure quality healthcare for eveyone. When this too fails, I predict two things:

– a hunt for and demonetization of saboteurs
– calls for more intervention

Leaked Memo: Afghan ‘Burn Pit’ Could Wreck Troops’ Hearts, Lungs

well, shit.

open quoteFor years, U.S. government agencies have told the public, veterans and Congress that they couldn’t draw any connections between the so-called “burn pits” disposing of trash at the military’s biggest bases and veterans’ respiratory or cardiopulmonary problems. But a 2011 Army memo obtained by Danger Room flat-out stated that the burn pit at one of Afghanistan’s largest bases poses “long-term adverse health conditions” to troops breathing the air there.

The unclassified memo (.jpg), dated April 15, 2011, stated that high concentrations of dust and burned waste present at Bagram Airfield for most of the war are likely to impact veterans’ health for the rest of their lives. “The long term health risk” from breathing in Bagram’s particulate-rich air include “reduced lung function or exacerbated chronic bronchitis, chronic obstructive pulmonary disease (COPD), asthma, atherosclerosis, or other cardiopulmonary diseases.” Service members may not necessarily “acquire adverse long term pulmonary or heart conditions,” but “the risk for such is increased.”close quote (Read more)

Blogging About the Paleo Diet Can Get You Shut Down in North Carolina

open quoteThe state of North Carolina has its own “Board of Dietetics and Nutrition”–of course it does–and it has decided that one bloggers right to free speech ends where the North Carolina Board of Dietetics and Nutrition’s officious overbearingness begins, as I think Oliver Wendell Holmes (or was it Oliver Wendell Douglas?) once wrote.

Here’s the naughty bits, as reported in Carolina Journal:

[When] Steve Cooksey…was hospitalized with diabetes in February 2009, he decided to avoid the fate of his grandmother, who eventually died of the disease. He embraced the low-carb, high-protein Paleo diet, also known as the “caveman” or “hunter-gatherer” diet. The diet, he said, made him drug- and insulin-free within 30 days. By May of that year, he had lost 45 pounds and decided to start a blog about his success.

But this past January the state diatetics and nutrition board decided Cooksey’s blog — Diabetes-Warrior.net — violated state law. The nutritional advice Cooksey provides on the site amounts to “practicing nutrition,” the board’s director says, and in North Carolina that’s something you need a license to do.

Unless Cooksey completely rewrites his 3-year-old blog, he could be sued by the licensing board. If he loses the lawsuit and refuses to take down the blog, he could face up to 120 days in jail.

The board’s director says Cooksey has a First Amendment right to blog about his diet, but he can’t encourage others to adopt it unless the state has certified him as a dietitian or nutritionist.

Seems he came to their attention after contradicting a local hospital’s director of diabetes services at a local meeting, and handing out cards about his site. What did the Board find objectionable about Cooksey’s site?close quote (Read more)

Walnuts are DRUGS! FDA makes bizarre claim after seller says they ‘reduce risk of heart disease and cancer’

open quoteThey may just be the hardest drugs on the market, if the FDA are to be believed.

A company which sells walnuts has been told they are dealing in drugs because their packaging suggests health benefits which the Food and Drug Administration has not approved, it has been reported.

A fiercely-worded letter from the agency allegedly insisted Diamond Foods, from Stockton, California, remove the health claims or send off for a new drug application if it did not wish to be closed down.

The nut company has been selling its products with packaging which states the omega-3 fatty acids in walnuts have been shown to reduce the risk of heart disease and some types of cancer.

But while the claims are backed up by research, including 35 published medical papers supporting assertions that eating walnuts improves vascular health and may reduce risk of heart attacks, the FDA is said to have insisted the company is ‘misbranding’ its foods because the ‘product bears health claims that are not authorised by the FDA’.close quote (Read more)