"There's a sucker born every minute": False and inflated health claims

“There is,” in a phrase rightly or wrongly attributed to P.T. Barnum, “a sucker born every minute.” To Barnum, and to countless others before and since, this was a business opportunity. They can get rich off us because we want stuff to be true even when every input from our senses should show us that it isn’t; we want magical, easy cures and money-making schemes, even when we know that they only work for the scheme’s designers, not the suckers who take the bait. Betsy DeVos, the recently approved Secretary of Education, who knows nothing about education and devalues public education (I could go on, but that’s another story…) is the beneficiary of such desires. She is in the position that she is in because of her great wealth which has bought her great influence, and that great wealth, at least the portion from her husband’s side, derives from the Ponzi scheme known as Amway. It is clear that Amway was in fact the path to wealth that it was claimed to be, for the DeVoses anyway.

The persistent and widespread greed of people despite evidence that the odds are stacked way against them is testimony to either optimism or stupidity, or some of both. It is one of the oldest memes in literature, from the alchemists who would turn lead into gold (or Rumpelstiltskin who would weave it) to Faust who would sell his soul to the devil (and maybe so did guitarist Robert Johnson) to Ralph Kramden (and his cartoon successor Fred Flintstone) and George “Kingfish” Stevens, doubly oppressed and vulnerable, being poor and black. And the outcome is always the same, the little guy gets screwed.

We could go on and on with this theme. The temptation to tie it to the election and reign of Donald Trump is enormous; people want something to be true (that they’ll get good jobs back, that their streets will be safe, that they can have all the health care they want and need without paying for it when they don’t need it, whatever) and Trump promised it all, and of course he is not and will not deliver, but many still love him. If you want a good article about this, try Matt Taibbi in Rolling Stone, “The end of facts in the Trump era”. But, after all, this blog is about public health and medicine, and there is no shortage of examples in those fields. After all, con men and grifters, whether low level hucksters, Amway merchants, or Wall Street bankers are all regularly called “snake oil salesmen”, and what was snake oil but a promise of better health? And the liniment sold by these folks might have worked a bit since it had red pepper, a bit like current capsaicin. When they were convicted it was because their oil did not come from snakes, not because it was a fraudulent cure.

You’d think that people would wonder why, if there is a miracle easy (and sometimes even relatively cheap) cure for all their ills that everyone else hasn’t benefited from it. Ah, but that is part of the attraction – being in the know about something everyone else isn’t. Is that not the way that inside traders work? Isn’t that how they fix sporting events, how your brother-in-law knows that this 100-1 shot will come in at Santa Anita? Is that not how Arnold Rothstein got rich? So, sure, it’s done in health. Watch daytime television sometime. It is mostly about medicine, from Dr. Oz (a font of misinformation), to an electric scooter you can get FREE (or at no cost to you, other than as a taxpayer paying into Medicare), or a miracle drug that will allow you to have even better relief from your arthritis or asthma or will keep your blood from clotting even better than warfarin, at only 1000 times the price, and at great potential risk to your immune system.

The hucksters present not only misinformation about individual medical care, but also public health. The most obvious, and likely most serious, current issue is that of vaccines. Despite there being no evidence linking vaccines to autism, and strong evidence showing there is no link, the myth persists. The price will likely be serious outbreaks of vaccine-preventable diseases, especially measles, as discussed by Peter J. Hoetz in his NY Times Op-Ed “How the anti-vaxxers are winning”, February 7, 2017. Water fluoridation suffers from similar myths. Public health may be even more susceptible to such hype than medical care, since so many of its benefits are things (like measles, or tooth decay) that don’t happen, rather than those that do. We rarely wake up saying “Gee, I’m glad I don’t have cholera today because we have clean water”; indeed, we mostly worry about water quality when something specifically bad is happening, like lead poisoning in Flint. People are susceptible to liars and charlatans who tell them things that they want to believe, as well as things that seem to make sense, but as I tell students, something that seems to make sense is called a research question; only when the study is done will we know if it is true.

But it is not only the more obvious (to the discerning, anyway) scams. Mainstream medicine does it often. Every new discovery, every potential ameliorant (if not cure) is trumpeted by both the companies that manufacture it and, at an earlier stage, the university for which they work. Of course, most of these discoveries are scarcely the magic breakthroughs that they are initially claimed to be. That is the nature of science; things are learned and knowledge grows incrementally. But a new discovery by a scientist at your university is worth a lot of publicity! Maybe it is a cure for Alzheimers! Or at least a step in that direction! Certainly worth millions of dollars more in NIH funding! There is nothing wrong in incremental discoveries; the problem is when they are hyped as the Holy Grail. Indeed, on July 16, 2010, I wrote about Rosiglitazone and the "Holy Grail", and how disappointed diabetes advocates were that Avandia® was being taken off the market just because it caused heart disease, because it did lower blood sugar! (A diabetes advocate noted that lowering blood sugar was the “Holy Grail”.) This story is a terrific example of the peskiness caused by the human body being an integral organism; something that is very good for one condition may still cause big problems. And so, maybe we should wait before we hype it too much. On the other hand, what an opportunity we have to get big publicity before that happens…

A recent example involves using low-dose CT screening for lung cancer. The US Preventive Services Task Force recommends it (as a “B” recommendation) for men 55-80 years old with a history of smoking. This “B” recommendation is worth a lot to the CT manufacturers and radiologists who read them, since the ACA requires insurers to cover USPSTF “A” and “B” recommendations. But a big Veterans Administration study just published in JAMA shows that it is not quite as good as previously thought. “Of the 2106 patients screened, 1257 (59.7%) had nodules; 1184 of these patients (56.2%) required tracking, 42 (2.0%) required further evaluation but the findings were not cancer, and 31 (1.5%) had lung cancer.” Does this mean that it is a bad idea to get screened? Not necessarily; if I had a patient with a significant smoking history, I would discuss the risks inherent in getting this procedure but prepare them for the probability that even a positive test would likely not mean they had cancer, and that they might have to undergo more procedures with some risk to find out. The point is not that this is a bad idea, but it is not some amazing breakthrough, as touted.

Just because you want to get rich quick, or avoid needle sticks, or find the magic cure for your arthritis or cancer that has been denied you, and someone is selling something that claims to do it, doesn’t make it true. If you think so, I’ve got a couple of bridges to sell you.

Fluoridation: Dental health for all

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Fluoridation of the water supply is one of the great public health benefits of the 20^th century. It is also one of the persistently more controversial. Ideological opposition (to “the government” doing anything) has mixed with paranoia (they are poisoning us) to create a pretty sustained grass-roots movement, one that has blocked this effort in many places in the country. Now, according to Lizette Alvarez’ article in the NY Times “Looking to save money, more places decide to stop fluoridating the water” (October 14, 2011), saving money has been added to these arguments. The threat is that communities which have had the benefits of fluoridated water will lose them. This is apparently the what is happening in Pinellas County, Florida (the Clearwater/St. Petersburg area), as well as in Fairbanks, Alaska.

The situations in Florida and Alaska may well be different, however. The decision in Fairbanks is apparently tied to the relatively high levels of naturally-occurring fluoride in the water there, which would make fluoridation an unnecessary cost. In Florida, however, the decision seems to be driven by cost as well as the same issues I note above. “I’m in opposition to putting a medical treatment into the public drinking water supply without a vote of the people who drink that water,” said Norm Roche, a newly elected Republican county commissioner who spent 10 years doing policy research for the county Water Department and who led the turnaround effort. “We had a dozen to 15 doctors, dentists, dental hygienists and chemists here who want us to continue this practice but who could not agree themselves on how best to use fluoride.” The article does not further define what Mr. Roche means by “how best to use”, leaving us to imagine if this is an issue of putting it in the water vs another method (fluoridated toothpaste, fluoride treatments at home, fluoride varnishes by health providers) or disagreement as to whether it should be used at all.

In fact, the medical and dental community are pretty much in agreement that fluoride is good for preventing tooth decay, and that dental caries are a major cause of disability both medically and socially. It is hard for a child with a toothache to concentrate at school, not to mention the teasing that can come from having a mouthful of rotting teeth. This latter continues into adulthood; people with bad teeth (or no teeth) are seen as less smart and less competent, and are less likely to be hired in most jobs.

Fluoride works. In my “middle years”, my Chicago dentist had a pretty good idea of my age because he knew when the water in New York City, where I grew up, was first fluoridated. My “6-year molars” were covered with filled cavities (necessitating, all those years later, a lot of restoration work by him), while my “12-year molars”, which erupted after fluoridation, were almost cavity-free.  I sure remember getting all those cavities filled, before dentists had high-speed drills or used anesthesia for such a simple, common procedure. My childhood self would certainly advocate for fluoride to prevent that discomfort!

There are, indeed, side effects to high levels of fluoride, whether naturally occurring or otherwise. The main sign of “fluorosis” is “marble teeth disease”, with “grotesque” brown staining of the teeth. It was an investigation into this condition in Colorado Springs in 1909 that led to the discovery both that the cause was high fluoride levels in the water, and that these teeth had virtually no decay (“The Story of Fluoride”, from the National Institutes of Dental and Craniofacial Research). This led to work that identified a level of fluoride that could be added to drinking water that was sufficient to prevent decay but too low to produce this condition.

After spending most of my life in New York and Chicago, one of the most dramatic things to catch my attention early in my stay in San Antonio, Texas, were the young children with stainless steel teeth, whose mouths distressingly reminded me of “Jaws”, the James Bond villain (albeit without the points!). I soon learned two things: 1) the stainless steel teeth were the result of having a great pediatric dental program at our dental school which could fix the mouths of children whose “baby teeth” had all rotted out, allowing them to be both pain-free and able to eat, and 2) the water in San Antonio was not fluoridated, which was a major cause (in combination with other behaviors, such as use of sugared drinks in baby bottles, feeding sugared soft-drinks to young children beyond the bottle years,  and “bottle propping” which leaves the milk – and milk sugar – in the baby’s mouth) of the decay the led to the need for such repair. While only a small percentage of children in San Antonio had such stainless steel teeth, a very large percentage had significant and disabling tooth decay.

I also discovered that efforts to pass fluoridation had been defeated in San Antonio on at least two occasions in the past few decades. The opposition was largely from right-wing, John Birch Society, anti-government groups, but also included those who were from the other end of the political spectrum but believed in “natural” health, and thus opposed addition of fluoride. In 2002, an initiative spearheaded by the Mayor of San Antonio, finally led to passage of fluoridation for that city. During this campaign, virtually all the major politicians, all the dentists, physicians, and public health people, and most of the foundations and money were for the initiative. Nonetheless, it passed by only 52% of the vote. The good news here, I guess, is that it is an example of the power of regular people, not very well funded, to resist change being imposed on them. Unfortunately, it was contrary to their health interests.

As I note, the opposition was not solely from the right. During my time in San Antonio, I frequently attended open meetings of a group of progressives in a local Mexican restaurant. Primarily mainstream liberal Democrats, and including the late San Antonio New Deal mayor and newspaper columnist, Maury Maverick, the group was diverse, including socialists and “Greens” and even libertarians, whose interests in lack of government restrictions and privacy invasions gave them common cause. These last two groups, the Greens and libertarians, were opposed to fluoridation. The national Green presidential candidate, Ralph Nader, on a stop in San Antonio, even came out in opposition to the initiative. As a health care provider, I did my best to argue for the benefits of fluoridation, but was unable to win them over.

One argument made they made (at least the libertarians) was that “fluoride might be beneficial, but the government should not put it in our water supply”. Parents could use fluoridated toothpaste or fluoride rinses on their children’s teeth, or bring them to the dentist for fluoride varnish. Well, they could, but often they didn’t, and it was the children who would suffer the caries and their long-term consequences. Indeed in the ‘90s a new syndrome, dubbed “yuppie baby carie syndrome” was identified in children of well-off parents who made their infant formula with bottled water. (The causes of caries from bottle propping and unfluoridated water are well-described in the Wikipedia entry on “Early Childhood Caries”.) Of course, the spread of bottled water to a much wider socioeconomic group makes this even a bigger potential problem. Indeed, some water from natural springs contains minerals, sometimes including fluoride, while the bigger mass-products products from Coke – Dasani – and Pepsi – Aquafina – are municipal tap water that has been “purified” and thus do not.  (This does not even begin to touch on all the environmental costs of bottled tap water, from plastic bottles to transporting tap water from one part of the country to another, but that’s another story.)

San Antonio, and more recently San Diego, are victories for fluoridation, while many cities, such as Wichita, remain unfluoridated, and others, such as Pinellas County and Fairbanks are going the other way. If Fairbanks has sufficient natural fluoride, then supplementation is an unnecessary cost. For those communities without adequate natural fluoride, it is a big mistake.

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