Sunday, December 16, 2007

Albert Einstein: Science and Religion

Albert Einstein: Science and Religion

Science and Religion
By Albert Einstein

This article is taken from:
Science, Philosophy and Religion, A Symposium

The Conference on Science, Philosophy and Religion in Their Relation to the Democratic Way of Life, Inc.
New York, 1941.

It would not be difficult to come to an agreement as to what we understand by science. Science is the century-old endeavor to bring together by means of systematic thought the perceptible phenomena of this world into as thoroughgoing an association as possible. To put it boldly, it is the attempt at the posterior reconstruction of existence by the process of conceptualization. But when asking myself what religion is I cannot think of the answer so easily. And even after finding an answer which may satisfy me at this particular moment, I still remain convinced that I can never under any circumstances bring together, even to a slight extent, the thoughts of all those who have given this question serious consideration.

At first, then, instead of asking what religion is I should prefer to ask what characterizes the aspirations of a person who gives me the impression of being religious: a person who is religiously enlightened appears to me to be one who has, to the best of his ability, liberated himself from the fetters of his selfish desires and is preoccupied with thoughts, feelings, and aspirations to which he clings because of their superpersonalvalue. It seems to me that what is important is the force of this superpersonal content and the depth of the conviction concerning its overpowering meaningfulness, regardless of whether any attempt is made to unite this content with a divine Being, for otherwise it would not be possible to count Buddha and Spinoza as religious personalities. Accordingly, a religious person is devout in the sense that he has no doubt of the significance and loftiness of those superpersonal objects and goals which neither require nor are capable of rational foundation. They exist with the same necessity and matter-of-factness as he himself. In this sense religion is the age-old endeavor of mankind to become clearly and completely conscious of these values and goals and constantly to strengthen and extend their effect. If one conceives of religion and science according to these definitions then a conflict between them appears impossible. For science can only ascertain what is, but not what should be, and outside of its domain value judgments of all kinds remain necessary. Religion, on the other hand, deals only with evaluations of human thought and action: it cannot justifiably speak of facts and relationships between facts. According to this interpretation the well-known conflicts between religion and science in the past must all be ascribed to a misapprehension of the situation which has been described.

For example, a conflict arises when a religious community insists on the absolute truthfulness of all statements recorded in the Bible. This means an intervention on the part of religion into the sphere of science; this is where the struggle of the Church against the doctrines of Galileo and Darwin belongs. On the other hand, representatives of science have often made an attempt to arrive at fundamental judgments with respect to values and ends on the basis of scientific method, and in this way have set themselves in opposition to religion. These conflicts have all sprung from fatal errors.

Now, even though the realms of religion and science in themselves are clearly marked off from each other, nevertheless there exist between the two strong reciprocal relationships and dependencies. Though religion may be that which determines the goal, it has, nevertheless, learned from science, in the broadest sense, what means will contribute to the attainment of the goals it has set up. But science can only be created by those who are thoroughly imbued with the aspiration toward truth and understanding. This source of feeling, however, springs from the sphere of religion. To this there also belongs the faith in the possibility that the regulations valid for the world of existence are rational, that is, comprehensible to reason. I cannot conceive of a genuine scientist without that profound faith. The situation may be expressed by an image: science without religion is lame, religion without science is blind.

Though I have asserted above that in truth a legitimate conflict between religion and science cannot exist, I must nevertheless qualify this assertion once again on an essential point, with reference to the actual content of historical religions. This qualification has to do with the concept of God. During the youthful period of mankind's spiritual evolution human fantasy created gods in man's own image, who, by the operations of their will were supposed to determine, or at any rate to influence, the phenomenal world. Man sought to alter the disposition of these gods in his own favor by means of magic and prayer. The idea of God in the religions taught at present is a sublimation of that old concept of the gods. Its anthropomorphic character is shown, for instance, by the fact that men appeal to the Divine Being in prayers and plead for the fulfillment of their wishes.

Nobody, certainly, will deny that the idea of the existence of an omnipotent, just, and omnibeneficent personal God is able to accord man solace, help, and guidance; also, by virtue of its simplicity it is accessible to the most undeveloped mind. But, on the other hand, there are decisive weaknesses attached to this idea in itself, which have been painfully felt since the beginning of history. That is, if this being is omnipotent, then every occurrence, including every human action, every human thought, and every human feeling and aspiration is also His work; how is it possible to think of holding men responsible for their deeds and thoughts before such an almighty Being? In giving out punishment and rewards He would to a certain extent be passing judgment on Himself. How can this be combined with the goodness and righteousness ascribed to Him?

The main source of the present-day conflicts between the spheres of religion and of science lies in this concept of a personal God. It is the aim of science to establish general rules which determine the reciprocal connection of objects and events in time and space. For these rules, or laws of nature, absolutely general validity is required--not proven. It is mainly a program, and faith in the possibility of its accomplishment in principle is only founded on partial successes. But hardly anyone could be found who would deny these partial successes and ascribe them to human self-deception. The fact that on the basis of such laws we are able to predict the temporal behavior of phenomena in certain domains with great precision and certainty is deeply embedded in the consciousness of the modern man, even though he may have grasped very little of the contents of those laws. He need only consider that planetary courses within the solar system may be calculated in advance with great exactitude on the basis of a limited number of simple laws. In a similar way, though not with the same precision, it is possible to calculate in advance the mode of operation of an electric motor, a transmission system, or of a wireless apparatus, even when dealing with a novel development.

To be sure, when the number of factors coming into play in a phenomenological complex is too large, scientific method in most cases fails us. One need only think of the weather, in which case prediction even for a few days ahead is impossible. Nevertheless no one doubts that we are confronted with a causal connection whose causal components are in the main known to us. Occurrences in this domain are beyond the reach of exact prediction because of the variety of factors in operation, not because of any lack of order in nature.

We have penetrated far less deeply into the regularities obtaining within the realm of living things, but deeply enough nevertheless to sense at least the rule of fixed necessity. One need only think of the systematic order in heredity, and in the effect of poisons, as for instance alcohol, on the behavior of organic beings. What is still lacking here is a grasp of connections of profound generality, but not a knowledge of order in itself.

The more a man is imbued with the ordered regularity of all events the firmer becomes his conviction that there is no room left by the side of this ordered regularity for causes of a different nature. For him neither the rule of human nor the rule of divine will exists as an independent cause of natural events. To be sure, the doctrine of a personal God interfering with natural events could never be refuted, in the real sense, by science, for this doctrine can always take refuge in those domains in which scientific knowledge has not yet been able to set foot.

But I am persuaded that such behavior on the part of the representatives of religion would not only be unworthy but also fatal. For a doctrine which is able to maintain itself not in clear light but only in the dark, will of necessity lose its effect on mankind, with incalculable harm to human progress. In their struggle for the ethical good, teachers of religion must have the stature to give up the doctrine of a personal God, that is, give up that source of fear and hope which in the past placed such vast power in the hands of priests. In their labors they will have to avail themselves of those forces which are capable of cultivating the Good, the True, and the Beautiful in humanity itself. This is, to be sure, a more difficult but an incomparably more worthy task. (This thought is convincingly presented in Herbert Samuel's book, Belief and Action.) After religious teachers accomplish the refining process indicated they will surely recognize with joy that true religion has been ennobled and made more profound by scientific knowledge.

If it is one of the goals of religion to liberate mankind as far as possible from the bondage of egocentric cravings, desires, and fears, scientific reasoning can aid religion in yet another sense. Although it is true that it is the goal of science to discover rules which permit the association and foretelling of facts, this is not its only aim. It also seeks to reduce the connections discovered to the smallest possible number of mutually independent conceptual elements. It is in this striving after the rational unification of the manifold that it encounters its greatest successes, even though it is precisely this attempt which causes it to run the greatest risk of falling a prey to illusions. But whoever has undergone the intense experience of successful advances made in this domain is moved by profound reverence for the rationality made manifest in existence. By way of the understanding he achieves a far-reaching emancipation from the shackles of personal hopes and desires, and thereby attains that humble attitude of mind toward the grandeur of reason incarnate in existence, and which, in its profoundest depths, is inaccessible to man. This attitude, however, appears to me to be religious, in the highest sense of the word. And so it seems to me that science not only purifies the religious impulse of the dross of its anthropomorphism but also contributes to a religious spiritualization of our understanding of life.

The further the spiritual evolution of mankind advances, the more certain it seems to me that the path to genuine religiosity does not lie through the fear of life, and the fear of death, and blind faith, but through striving after rational knowledge. In this sense I believe that the priest must become a teacher if he wishes to do justice to his lofty educational mission.

Medical Guesswork

Medical Guesswork

COVER STORY

From heart surgery to prostate care, the health industry knows little about which common treatments really work

By John Carey
Businessweek
May 29, 2006

The signs at the meeting were not propitious. Half the board members of Kaiser Permanente's Care Management Institute left before Dr. David Eddy finally got the 10 minutes he had pleaded for. But the message Eddy delivered was riveting. With a groundbreaking computer simulation, Eddy showed that the conventional approach to treating diabetes did little to prevent the heart attacks and strokes that are complications of the disease. In contrast, a simple regimen of aspirin and generic drugs to lower blood pressure and cholesterol sent the rate of such incidents plunging. The payoff: healthier lives and hundreds of millions in savings. "I told them: 'This is as good as it gets to improve care and lower costs, which doesn't happen often in medicine,"' Eddy recalls. "'If you don't implement this,' I said, 'you might as well close up shop."'

The message got through. Three years later, Kaiser is in the midst of a major initiative to change the treatment of the diabetics in its care. "We're trying to put nearly a million people on these drugs," says Dr. Paul Wallace, senior adviser to the Care Management Institute. The early results: The strategy is indeed improving care and cutting costs, just as Eddy's model predicted.

For Eddy, this is one small step toward solving the thorniest riddle in medicine -- a dark secret he has spent his career exposing. "The problem is that we don't know what we are doing," he says. Even today, with a high-tech health-care system that costs the nation $2 trillion a year, there is little or no evidence that many widely used treatments and procedures actually work better than various cheaper alternatives.

This judgment pertains to a shocking number of conditions or diseases, from cardiovascular woes to back pain to prostate cancer. During his long and controversial career proving that the practice of medicine is more guesswork than science, Eddy has repeatedly punctured cherished physician myths. He showed, for instance, that the annual chest X-ray was worthless, over the objections of doctors who made money off the regular visit. He proved that doctors had little clue about the success rate of procedures such as surgery for enlarged prostates. He traced one common practice -- preventing women from giving birth vaginally if they had previously had a cesarean -- to the recommendation of one lone doctor. Indeed, when he began taking on medicine's sacred cows, Eddy liked to cite a figure that only 15% of what doctors did was backed by hard evidence.

Quiz >>
A great many doctors and health-care quality experts have come to endorse Eddy's critique. And while there has been progress in recent years, most of these physicians say the portion of medicine that has been proven effective is still outrageously low -- in the range of 20% to 25%. "We don't have the evidence [that treatments work], and we are not investing very much in getting the evidence," says Dr. Stephen C. Schoenbaum, executive vice-president of the Commonwealth Fund and former president of Harvard Pilgrim Health Care Inc. "Clearly, there is a lot in medicine we don't have definitive answers to," adds Dr. I. Steven Udvarhelyi, senior vice-president and chief medical officer at Pennsylvania's Independence Blue Cross.

What's required is a revolution called "evidence-based medicine," says Eddy, a heart surgeon turned mathematician and health-care economist. Tall, lean, and fit at 64, Eddy has the athletic stride and catlike reflexes of the ace rock climber he still is. He also exhibits the competitive drive of someone who once obsessively recorded his time on every training run, and who still likes to be first on a brisk walk up a hill near his home in Aspen, Colo. In his career, he has never been afraid to take a difficult path or an unpopular stand. "Evidence-based" is a term he coined in the early 1980s, and it has since become a rallying cry among medical reformers. The goal of this movement is to pierce the fog that envelops the practice of medicine -- a state of ignorance for which doctors cannot really be blamed. "The limitation is the human mind," Eddy says. Without extensive information on the outcomes of treatments, it's fiendishly difficult to know the best approach for care.

The human brain, Eddy explains, needs help to make sense of patients who have combinations of diseases, and of the complex probabilities involved in each. To provide that assistance, Eddy has spent the past 10 years leading a team to develop the computer model that helped him crack the diabetes puzzle. Dubbed Archimedes, this program seeks to mimic in equations the actual biology of the body, and make treatment recommendations as well as figure out what each approach costs. It is at least 10 times "better than the model we use now, which is called thinking," says Dr. Richard Kahn, chief scientific officer at the American Diabetes Assn.

WASTED RESOURCES
Can one computer program offset all the ill-advised treatment options for a whole range of different diseases? The milestones in Eddy's long personal crusade highlight the looming challenges, and may offer a sliver of hope. Coming from a family of four generations of doctors, Eddy went to medical school "because I didn't know what else to do," he confesses. As a resident at Stanford Medical Center in the 1970s, he picked cardiac surgery because "it was the biggest hill -- the glamour field."

But he soon became troubled. He began to ask if there was actual evidence to support what doctors were doing. The answer, he was surprised to hear, was no. Doctors decided whether or not to put a patient in intensive care or use a combination of drugs based on their best judgment and on rules and traditions handed down over the years, as opposed to real scientific proof. These rules and judgments weren't necessarily right. "I concluded that medicine was making decisions with an entirely different method from what we would call rational," says Eddy.

About the same time, the young resident discovered the beauty of mathematics, and its promise of answering medical questions. In just a couple of days, he devoured a calculus textbook (now framed on a shelf in his beautifully appointed home and office), then blasted through the books for a two-year math course in a couple of months. Next, he persuaded Stanford to accept him in a mathematically intense PhD program in the Engineering-Economics Systems Dept. "Dave came in -- just this amazing guy," recalls Richard Smallwood, then a Stanford professor. "He had decided he wanted to spend the rest of his life bringing logic and rationality to the medical system, but said he didn't have the math. I said: 'Why not just take it?' So he went out and aced all those math courses."

To augment his wife's earnings while getting his PhD, Eddy landed a job at Xerox Corp.'s (XRX ) legendary Palo Alto Research Center. "They hired weird people," he says. "Here was a heart surgeon doing math. That was weird enough."

Eddy used his newfound math skills to model cancer screening. His Stanford PhD thesis made front-page news in 1980 by overturning the guidelines of the time. It showed that annual chest X-rays and yearly Pap smears for women at low risk of cervical cancer were a waste of resources, and it won the most prestigious award in the field of operations research, the Frederick W. Lanchester prize. Based on his results, the American Cancer Society changed its guidelines. "He's smart as hell, with a towering clarity of thought," says Stanford health economist Allan Enthoven.

Dr. William H. Herman, director of the Michigan Diabetes Research & Training Center, has a competing computer model that clashes with Eddy's. Nonetheless, he says, "Dr. Eddy is one of my heroes. He's sort of the father of health economics -- and he might be right."

Appointed a full professor at Stanford, then recruited as chairman of the Center for Health Policy Research & Education at Duke University, Eddy proved again and again that the emperor had no clothes. In one study, he ferreted out decades of research evaluating treatment of high pressure in the eyeball, a condition that can lead to glaucoma and blindness. He found about a dozen studies that looked at outcomes with pressure-lowering medications used on millions of people. The studies actually suggested that the 100-year-old treatment was harmful, causing more cases of blindness, not fewer.

Eddy submitted a paper to the Journal of the American Medical Assn. (JAMA), whose editors sent it out to specialists for review. "It was amazing," Eddy recalls. "The tom-toms sounded among all the ophthalmologists," who marshaled a counterattack. "I felt like Salman Rushdie." Stanford ophthalmologist Kuldev Singh says: "Dr. Eddy challenged the community to prove that we actually had evidence. He did a service by stimulating clinical trials," which showed that the treatment does slow the disease in a minority of patients.

By 1985, Eddy was "burned out" by the administrative side of academia, he says. Lured by a poster of the Tetons, he gave up his prestigious post. He moved to Jackson, Wyo., so he could climb in his spare time. He and a friend even made a first ascent of a new route on the Grand Teton, now named after them. Meanwhile, he carved out a niche showing doctors at specialty society meetings that their cherished beliefs were dubious. "At each meeting I would do the same exercise," he says. He would ask doctors to think of a typical patient and typical treatment, then write down the results of that treatment. For urologists, for instance, what were the chances that a man with an enlarged prostate could urinate normally after having corrective surgery? Eddy then asked the society's president to read the predictions.

The results were startling. The predictions of success invariably ranged from 0% to 100%, with no clear pattern. "All the doctors were trying to estimate the same thing -- and they all gave different numbers," he says. "I've spent 25 years proving that what we lovingly call clinical judgment is woefully outmatched by the complexities of medicine." Think about the implications for helping patients make decisions, Eddy adds. "Go to one doctor, and get one answer. Go to another, and get a different one." Or think about expert testimony. "You don't have to hire an expert to lie. You can just find one who truly believes the number you want."

More important, the lack of evidence creates a costly clash. Americans and their doctors want access to any new treatment, and many doctors fervently believe such care is warranted. On the other hand, those beliefs can be flat wrong. As a consultant on Blue Cross's insurance coverage decisions, Eddy testified on the insurer's behalf in high-profile court cases, such as bone marrow transplants for breast cancer. Women and doctors demanded the treatment, even though there was no evidence it saved lives. Insurers who refused coverage usually lost in court. "I was the bad guy," Eddy recalls. When clinical trials were actually done, they showed that the treatment, costing from $50,000 to $150,000, didn't work. The doctors who pushed the painful, risky procedure on women "owe this country an apology," Eddy says.

Is medicine doing any better today? In recognizing the problem, yes. But in solving it, unfortunately, no. Take prostate cancer. Doctors now routinely test for levels of prostate-specific antigen (PSA) to try to diagnose the disease. But there's no evidence that using the test improves survival. Some experts believe that as many cancers would be detected through random biopsies. Then, once cancer is spotted, there's no way to know who needs treatment and who doesn't. Plus, there is a plethora of treatment choices -- four kinds of surgery, various types of implantable radioactive seeds, and competing external radiation regimens, notes Dr. Eric Klein, head of urologic oncology at the Cleveland Clinic. "How is a poor patient supposed to decide among those?" he asks. Most of the time, patients don't even know the options.

VESTED INTERESTS
"Because there are no definitive answers, you are at the whim of where you are and who you talk to," says Dr. Gary M. Kirsh at the Urology Group in Cincinnati. Kirsh does many brachytherapies -- implanting radioactive seeds. But "if you drive one and a half hours down the road to Indianapolis, there is almost no brachytherapy," he says. Head to Loma Linda, Calif., where the first proton-beam therapy machine was installed, in 1990, and the rates of proton-beam treatment are far higher than in most other parts of the country. Go to a surgeon, and he'll probably recommend surgery. Go to a radiologist, and the chances are high of getting radiation instead. "Doctors often assume that they know what a patient wants, leading them to recommend the treatment they know best," says Dr. David E. Wennberg, president of Health Dialog Analytic Solutions.

More troubling, many doctors hold not just a professional interest in which treatment to offer, but a financial one as well. "There is no question that the economic interests of the physician enter into the decision," says Kirsh. The bottom line: The conventional wisdom in prostate cancer -- that surgery is the gold standard and the best chance for a cure -- is unsustainable. Strangely enough, however, the choice may not matter very much. "There really isn't good evidence to suggest that one treatment is better than another," says Klein.

Compared with the skepticism Eddy faced in the 1990s, many physicians now concur that traditional treatments for serious illnesses often aren't best. Yet this message can be hard for Americans to believe. "When there is more than one medical option, people mistakenly think that the more aggressive procedure is the best," says Annette M. Cormier O'Connor, senior scientist in clinical epidemiology at the Ottawa Health Research Institute. The message flies in the face of America's infatuation with the latest advances. "As a nation, we always want the best, the most recent technology," explains Dr. Joe Thompson, health adviser to Arkansas Governor Mike Huckabee. "We spend a huge amount developing it, and we get a big increase in supply." New radiation machines for cancer or operating rooms for heart surgery are profit centers for hospitals, for instance (see BW Online, 07/18/05, "Is Heart Surgery Worth It?"). Once a hospital installs a shiny new catheter lab, it has a powerful incentive to refer more patients for the procedure. It's a classic case of increased supply driving demand, instead of the other way around. "Combine that with Americans' demand to be treated immediately, and it is a cauldron for overuse and inappropriate use," says Thompson.

The consequences for the U.S. are disturbing. This nation spends 2 1/2 times as much as any other country per person on health care. Yet middle-aged Americans are in far worse health than their British counterparts, who spend less than half as much and practice less intensive medicine, according to a new study. "The investment in health care in the U.S. is just not paying off," argues Gerard Anderson, director of the Center for Hospital Finance & Management at Johns Hopkins' Bloomberg School of Public Health. Speaking not for attribution, the head of health care at one of America's largest corporations puts it more bluntly: "There is a massive amount of spending on things that really don't help patients, and even put them at greater risk. Everyone that's informed on the topic knows it, but it is such a scary thing to discuss that people are not willing to talk about it openly."

Of course, there are plenty of areas of medicine, from antibiotics and vaccines to early detection of certain tumors, where the benefits are huge and incontrovertible. But if these effective treatments are black and white, much of the rest of medicine is a dark shade of gray. "A lot of things we absolutely believe at the moment based on our intuition are ultimately absolutely wrong," says Dr. Paul Wallace, of the Care Management Institute.

The best way to go from intuition to evidence is the randomized clinical trial. Patients with a particular condition are randomly assigned to competing treatments or, if appropriate, to a placebo. By monitoring the patients for months or years, doctors learn the relative risks and benefits of the treatment being studied.

But such trials take years and cost many millions of dollars. By the time the results come in, science and medicine may have moved on, making the findings less relevant. Moreover, patients in a clinical trial usually aren't representative of real people, who tend to have complex combinations of diseases and medical problems. And patients often don't stick with the program.

Such difficulties are highlighted by an eight-year study of low-fat diets that cost upward of $400 million. Most subjects failed to stick to the low-fat regimen, making it tough to draw conclusions. In addition, the study failed to take stock of different kinds of fats, some of which are now known to have beneficial effects. Many trials fall into similar traps. So it's no surprise that up to one-third of clinical studies lead to conclusions that are later overturned, according to a recent paper in JAMA.

Even when common treatments are proved to be dubious, physicians don't rush to change their practice. They may still firmly believe in the treatment -- or in the dollars it brings in. And doctors whose oxen get gored sometimes fight back. In 1993, the federal government's Agency for Health Care Policy & Research convened a panel to develop guidelines for back surgery. Fearing that the recommendations would cast doubt on what the doctors were doing, a prominent back surgeon protested to Congress, and lawmakers slashed funding for the agency. "Congress forced out the research," says Floyd J. Fowler Jr., president of the Foundation for Informed Medical Decision Making. "It was a national tragedy," he says -- and not an isolated incident. The agency's budget is often targeted "by special interest groups who had their specialty threatened," says Arkansas' Dr. Thompson.

With proof about medical outcomes lacking, one possible solution is educating patients about the uncertainties. "The popular version of evidence-based medicine is about proving things," says Kaiser's Wallace, "but it is really about transparency -- being clear about what we know and don't know." The Foundation for Informed Medical Decision Making produces booklets, videotapes, and other material to put the full picture in the hands of patients. Health Dialog markets the information to providers and companies, addressing back pain, breast cancer, uterine fibroids and bleeding, coronary heart disease, depression, osteoarthritis, and other conditions.

In studies where one group of patients hears the full story while other patients simply receive their doctors' instructions, a key difference emerges. The well-informed patients opt for more invasive, aggressive approaches 23% less often, on average, than the other group. In some cases, the drop is much bigger -- 50% to 60%. "Patients typically don't understand that they have options, and even if they do, they often wildly exaggerate the benefits of surgery and wildly minimize the chances of harm," says Ottawa's O'Connor, a leader in this field of so-called decision aids.

Eddy's computer simulation could help more patients attain appropriate care. His approach is to create a SimCity-like world in silicon, where virtual doctors conduct trials of virtual patients and figure out what treatments work. After getting funding from Kaiser Permanente in 1991, Eddy hired a particle physicist, Len Schlessinger, who knew how to write equations describing the complex interactions in biology. The pair selected diabetes as a test case. In their virtual world, each simulated person has a heart, liver, kidneys, blood, and other organs. As in real people, cells in the pancreas make insulin, which regulates the uptake of glucose in other cells. And as in the real disease, key cells can fail to respond to the insulin, causing high blood-sugar levels and a cascade of biological effects. The virtual patients come down with high blood pressure, heart disease, and poor circulation, which can lead to foot ulcers and amputations, blindness, and other ills. The model also assesses the costs of treating the complications.

Eddy dubbed the model Archimedes and tested it by comparing it with two dozen real trials. One clinical study compared cholesterol-lowering statin drugs to a placebo in diabetics. After 4 1/2 years, the drugs reduced heart attacks by 35%. The exact same thing happened in Eddy's simulated patients. "The Archimedes model is just fabulous in the validation studies," says the University of Michigan's Herman.

STANDARD OF CARE
The team then put Archimedes to work on a tough, real problem: how best to treat diabetes in people who have additional aliments. "One thing not yet adequately embraced by evidence-based medicine is what to do for someone with diabetes, hypertension, heart disease, and depression," explains Kaiser's Wallace. Doctors now typically try to treat the most pressing problems. "But we fail to pick the right ones consistently, so we have misdirected utilization and a great deal of waste," he says. Kaiser Permanente's Dr. Jim Dudl had a counterintuitive suggestion. With diabetics, doctors assume that keeping blood sugar levels low and consistent is the best way to ward off problems such as heart disease. But Dudl wondered what would happen if he flipped it around, aiming treatment at the downstream problems. The idea is to give patients a trio of generic medicines: aspirin, a cholesterol-lowering statin, and drugs called ACE inhibitors.

Using Archimedes and thousands of virtual patients, Eddy and Schlessinger compared the traditional approach with the drug combination. The model took about a half-hour to simulate a 30-year trial, and showed that the three-drug combination was "cost- and life-saving," says Kaiser's Wallace. The benefits far surpassed "what can be achieved with aggressive glucose control." Kaiser Permanente docs switched their standard of care for diabetes, adding these drugs to other interventions. It is too early to declare a victory, but the experience with patients seems to be mimicking Eddy's computer model. "It goes against our mental picture of the disease," says Wallace. But it also makes sense, he adds. "Cardiovascular disease is the worst complication of diabetes -- and what people die of."

Eddy readily concedes that this example is a small beginning. In its current state of development, Archimedes is like "the Wright brothers' plane. We're off the sand and flying to Raleigh." But it won't be long, he says, "before we're offering transcontinental flights, with movies."

The modeling approach allows each of us, in essence, to have an imaginary twin. We can use our twin to predict what our lives and state of health are likely to be with different lifestyles and approaches to care. Companies could create virtual clones of each employee, predicting what will occur with current care or with added prevention or treatment programs. "They can see what happens to such things as the complications suffered by diabetics, the lost time from work, the amount of angina or the rate of heart attacks, the number of deaths, and the cost of new employees if one dies," Eddy explains. "Our mission is that in 10 years, no one will make an important decision in health care without first asking: `What does Archimedes say?"'

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For Science's Gatekeepers, a Credibility Gap

For Science's Gatekeepers, a Credibility Gap

May 2, 2006
By LAWRENCE K. ALTMAN, M.D.
The New York Times

Recent disclosures of fraudulent or flawed studies in medical and scientific journals have called into question as never before the merits of their peer-review system.

The system is based on journals inviting independent experts to critique submitted manuscripts. The stated aim is to weed out sloppy and bad research, ensuring the integrity of the what it has published.

Because findings published in peer-reviewed journals affect patient care, public policy and the authors' academic promotions, journal editors contend that new scientific information should be published in a peer-reviewed journal before it is presented to doctors and the public.

That message, however, has created a widespread misimpression that passing peer review is the scientific equivalent of the Good Housekeeping seal of approval.

Virtually every major scientific and medical journal has been humbled recently by publishing findings that are later discredited. The flurry of episodes has led many people to ask why authors, editors and independent expert reviewers all failed to detect the problems before publication.

The publication process is complex. Many factors can allow error, even fraud, to slip through. They include economic pressures for journals to avoid investigating suspected errors; the desire to avoid displeasing the authors and the experts who review manuscripts; and the fear that angry scientists will withhold the manuscripts that are the lifeline of the journals, putting them out of business.By promoting the sanctity of peer review and using it to justify a number of their actions in recent years, journals have added to their enormous power.

The release of news about scientific and medical findings is among the most tightly managed in country. Journals control when the public learns about findings from taxpayer-supported research by setting dates when the research can be published. They also impose severe restrictions on what authors can say publicly, even before they submit a manuscript, and they have penalized authors for infractions by refusing to publish their papers. Exceptions are made for scientific meetings and health emergencies.

But many authors have still withheld information for fear that journals would pull their papers for an infraction. Increasingly, journals and authors' institutions also send out news releases ahead of time about a peer-reviewed discovery so that reports from news organizations coincide with a journal's date of issue.

A barrage of news reports can follow. But often the news release is sent without the full paper, so reports may be based only on the spin created by a journal or an institution.

Journal editors say publicity about corrections and retractions distorts and erodes confidence in science, which is an honorable business. Editors also say they are gatekeepers, not detectives, and that even though peer review is not intended to detect fraud, it catches flawed research and improves the quality of the thousands of published papers.

However, even the system's most ardent supporters acknowledge that peer review does not eliminate mediocre and inferior papers and has never passed the very test for which it is used. Studies have found that journals publish findings based on sloppy statistics. If peer review were a drug, it would never be marketed, say critics, including journal editors.

None of the recent flawed studies have been as humiliating as an article in 1972 in the journal Pediatrics that labeled sudden infant death syndrome a hereditary disorder, when, in the case examined, the real cause was murder.

Twenty-three years later, the mother was convicted of smothering her five children. Scientific naïveté surely contributed to the false conclusion, but a forensic pathologist was not one of the reviewers. The faulty research in part prompted the National Institutes of Health to spend millions of dollars on a wrong line of research.

Fraud, flawed articles and corrections have haunted general interest news organizations. But such problems are far more embarrassing for scientific journals because of their claims for the superiority of their system of editing.

A widespread belief among nonscientists is that journal editors and their reviewers check authors' research firsthand and even repeat the research. In fact, journal editors do not routinely examine authors' scientific notebooks. Instead, they rely on peer reviewers' criticisms, which are based on the information submitted by the authors.

While editors and reviewers may ask authors for more information, journals and their invited experts examine raw data only under the most unusual circumstances.

In that respect, journal editors are like newspaper editors, who check the content of reporters' copy for facts and internal inconsistencies but generally not their notes. Still, journal editors have refused to call peer review what many others say it is — a form of vetting or technical editing.

In spot checks, many scientists and nonscientists said they believed that editors decided what to publish by counting reviewers' votes. But journal editors say that they are not tally clerks and that decisions to publish are theirs, not the reviewers'.

Editors say they have accepted a number of papers that reviewers have harshly criticized as unworthy of publication and have rejected many that received high plaudits.

Many nonscientists perceive reviewers to be impartial. But the reviewers, called independent experts, in fact are often competitors of the authors of the papers they scrutinize, raising potential conflicts of interest.

Except when gaffes are publicized, there is little scrutiny of the quality of what journals publish.

Journals have rejected calls to make the process scientific by conducting random audits like those used to monitor quality control in medicine. The costs and the potential for creating distrust are the most commonly cited reasons for not auditing.

In defending themselves, journal editors often shift blame to the authors and excuse themselves and their peer reviewers.

Journals seldom investigate frauds that they have published, contending that they are not investigative bodies and that they could not afford the costs. Instead, the journals say that the investigations are up to the accused authors' employers and agencies that financed the research.

Editors also insist that science corrects its errors. But corrections often require whistle-blowers or prodding by lawyers. Editors at The New England Journal of Medicine said they would not have learned about a problem that led them to publish two letters of concern about omission of data concerning the arthritis drug Vioxx unless lawyers for the drug's manufacturer, Merck, had asked them questions in depositions. Fraud has also slipped through in part because editors have long been loath to question the authors.

"A request from an editor for primary data to support the honesty of an author's findings in a manuscript under review would probably poison the air and make civil discourse between authors and editors even more difficult than it is now," Dr. Arnold S. Relman wrote in 1983. At the time, he was editor of The New England Journal of Medicine, and it had published a fraudulent paper.

Fraud is a substantial problem, and the attitude toward it has changed little over the years, other editors say. Some journals fail to retract known cases of fraud for fear of lawsuits.

Journals have no widely accepted way to retract papers, said Donald Kennedy, editor in chief of Science, after the it retracted two papers by the South Korean researcher Dr. Hwang Woo Suk, who fabricated evidence that he had cloned human cells.

In the April 18 issue of Annals of Internal Medicine, its editor, Dr. Harold C. Sox, wrote about lessons learned after the journal retracted an article on menopause by Dr. Eric Poehlman of the University of Vermont.

When an author is found to have fabricated data in one paper, scientists rarely examine all of that author's publications, so the scientific literature may be more polluted than believed, Dr. Sox said.

Dr. Sox and other scientists have documented that invalid work is not effectively purged from the scientific literature because the authors of new papers continue to cite retracted ones.

When journals try to retract discredited papers, Dr. Sox said, the process is slow, and the system used to inform readers faulty. Authors often use euphemisms instead of the words "fabrication" or "research misconduct," and finding published retractions can be costly because some affected journals charge readers a fee to visit their Web sites to learn about them, Dr. Sox said.

Despite its flaws, scientists favor the system in part because they need to publish or perish. The institutions where the scientists work and the private and government agencies that pay for their grants seek publicity in their eagerness to show financial backers results for their efforts.

The public and many scientists tend to overlook the journals' economic benefits that stem from linking their embargo policies to peer review. Some journals are owned by private for-profit companies, while others are owned by professional societies that rely on income from the journals. The costs of running journals are low because authors and reviewers are generally not paid.

A few journals that not long ago measured profits in the tens of thousands of dollars a year now make millions, according to at least three editors who agreed to discuss finances only if granted anonymity, because they were not authorized to speak about finances.

Any influential system that profits from taxpayer-financed research should be held publicly accountable for how the revenues are spent. Journals generally decline to disclose such data.

Although editors of some journals say they demand statements from their editing staff members that they have no financial conflicts of interest, there is no way to be sure. At least one editor of a leading American journal had to resign because of conflicts of interest with industry.

Journals have devolved into information-laundering operations for the pharmaceutical industry, say Dr. Richard Smith, the former editor of BMJ, the British medical journal, and Dr. Richard Horton, the editor of The Lancet, also based in Britain.

The journals rely on revenues from industry advertisements. But because journals also profit handsomely by selling drug companies reprints of articles reporting findings from large clinical trials involving their products, editors may "face a frighteningly stark conflict of interest" in deciding whether to publish such a study, Dr. Smith said.

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Drugs companies "inventing diseases to boost their profits"

Drugs companies "inventing diseases to boost their profits"

By Mark Henderson, Science Correspondent, The Times
April 11, 2006

PHARMACEUTICAL companies are systematically creating diseases in order to sell more of their products, turning healthy people into patients and placing many at risk of harm, a special edition of a leading medical journal claims today.

The practice of “diseasemongering” by the drug industry is promoting non-existent illnesses or exaggerating minor ones for the sake of profits, according to a set of essays published by the open-access journal Public Library of Science Medicine.

The special issue, edited by David Henry, of Newcastle University in Australia, and Ray Moynihan, an Australian journalist, reports that conditions such as female sexual dysfunction, attention deficit hyperactivity disorder (ADHD) and “restless legs syndrome” have been promoted by companies hoping to sell more of their drugs.

Other minor problems that are a normal part of life, such as symptoms of the menopause, are also becoming increasingly “medicalised”, while risk factors such as high cholesterol levels or osteoporosis are being presented as diseases in their own right, according to the editors.

“Disease-mongering turns healthy people into patients, wastes precious resources and causes iatrogenic (medically induced) harm,” they say. “Like the marketing strategies that drive it, disease-mongering poses a global challenge to those interested in public health, demanding in turn a global response.”

Doctors, patients and support groups need to be more aware that pharmaceutical companies are taking this approach, and more research is needed into the changing ways in which conditions are presented, according to the writers.

Disease-awareness campaigns are often funded by drug companies, and “more often designed to sell drugs than to illuminate or inform or educate about the prevention of illness or the maintenance of health”, they say.

Particular conditions that are highlighted in the journal include sexual function in both men and women. The prevalence of female sexual dysfunction, one paper claims, has been highly exaggerated to provide a new market for drugs, while the makers of anti-impotence medicines, such as Viagra and Cialis, have been involved with their presentation as lifestyle drugs that can boost the sexual prowess of healthy men.

Ordinary shyness is routinely presented as a social anxiety disorder and treated with antidepressants, while newly identified conditions such as “restless legs syndrome” — a constant urge to move one’s legs — are presented as being much more common than they really are.

Richard Ley, of the Association of the British Pharmaceutical Industry, rejected the accusations, pointing out that Britain has firm safeguards against disease-mongering. Many of the authors’ criticisms, he said, were aimed squarely at countries such as the United States, where pharmaceuticals can be openly advertised directly to patients.

“Drug companies are not allowed to communicate directly with patients, and we do not invent diseases,” he said.

“We provide information that there are treatments out there that might help certain conditions, but at the end of the day it is down to health professionals to decide if they are appropriate.

“The best safeguard is that the doctor who knows the product and knows the patient’s history is the one who decides what to prescribe.”

TRICK OR TREAT?

MENOPAUSE
Symptoms include hot flushes, night sweats and loss of libido
Criticism too often “medicalised” as part of a “disorder” when it is a normal phase of life

IRRITABLE BOWEL SYNDROME
Symptoms include constipation, cramps and diarrhoea
Criticism promoted by drug companies as a serious illness needing therapy, when it is usually a mild problem

SEXUAL DYSFUNCTION
Symptoms impotence in men, lack of libido or difficulty becoming aroused in women
Criticism drugs such as Viagra marketed not only for treating genuine erectile dysfunction caused by medical problems but as lifestyle improvers

OSTEOPOROSIS
Symptoms thinning of the bones, particularly among postmenopausal women
Criticism portrayed as a disease in its own right, when it is really a risk factor for broken bones

RESTLESS LEGS
Symptoms urge to move legs because of unpleasant feelings, often at night
Criticism prevalence of a relatively rare condition exaggerated by the media, along with the need for treatment

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Why Doctors So Often Get It Wrong

Why Doctors So Often Get It Wrong

February 22, 2006
By DAVID LEONHARDT, The New York Times

ON a weekend day a few years ago, the parents of a 4-year-old boy from rural Georgia brought him to a children's hospital here in north Atlanta. The family had already been through a lot. Their son had been sick for months, with fevers that just would not go away.

The doctors on weekend duty ordered blood tests, which showed that the boy had leukemia. There were a few things about his condition that didn't add up, like the light brown spots on the skin, but the doctors still scheduled a strong course of chemotherapy to start on Monday afternoon. Time, after all, was their enemy.

John Bergsagel, a soft-spoken senior oncologist, remembers arriving at the hospital on Monday morning and having a pile of other cases to get through. He was also bothered by the skin spots, but he agreed that the blood test was clear enough. The boy had leukemia.

"Once you start down one of these clinical pathways," Dr. Bergsagel said, "it's very hard to step off."

What the doctors didn't know was that the boy had a rare form of the disease that chemotherapy does not cure. It makes the symptoms go away for a month or so, but then they return. Worst of all, each round of chemotherapy would bring a serious risk of death, since he was already so weak.

With all the tools available to modern medicine — the blood tests and M.R.I.'s and endoscopes — you might think that misdiagnosis has become a rare thing. But you would be wrong. Studies of autopsies have shown that doctors seriously misdiagnose fatal illnesses about 20 percent of the time. So millions of patients are being treated for the wrong disease.

As shocking as that is, the more astonishing fact may be that the rate has not really changed since the 1930's. "No improvement!" was how an article in the normally exclamation-free Journal of the American Medical Association summarized the situation.

This is the richest country in the world — one where one-seventh of the economy is devoted to health care — and yet misdiagnosis is killing thousands of Americans every year.

How can this be happening? And how is it not a source of national outrage?

A BIG part of the answer is that all of the other medical progress we have made has distracted us from the misdiagnosis crisis.

Any number of diseases that were death sentences just 50 years ago — like childhood leukemia — are often manageable today, thanks to good work done by people like Dr. Bergsagel. The brightly painted pediatric clinic where he practices is a pretty inspiring place on most days, because it's just a detour on the way toward a long, healthy life for four out of five leukemia patients who come here.

But we still could be doing a lot better. Under the current medical system, doctors, nurses, lab technicians and hospital executives are not actually paid to come up with the right diagnosis. They are paid to perform tests and to do surgery and to dispense drugs.

There is no bonus for curing someone and no penalty for failing, except when the mistakes rise to the level of malpractice. So even though doctors can have the best intentions, they have little economic incentive to spend time double-checking their instincts, and hospitals have little incentive to give them the tools to do so.

"You get what you pay for," Mark B. McClellan, who runs Medicare and Medicaid, told me. "And we ought to be paying for better quality."

There are some bits of good news here. Dr. McClellan has set up small pay-for-performance programs in Medicare, and a few insurers are also experimenting. But it isn't nearly a big enough push. We just are not using the power of incentives to save lives. For a politician looking to make the often-bloodless debate over health care come alive, this is a huge opportunity.

Joseph Britto, a former intensive-care doctor, likes to compare medicine's attitude toward mistakes with the airline industry's. At the insistence of pilots, who have the ultimate incentive not to mess up, airlines have studied their errors and nearly eliminated crashes.

"Unlike pilots," Dr. Britto said, "doctors don't go down with their planes."

Dr. Britto was working at a London hospital in 1999 when doctors diagnosed chicken pox in a little girl named Isabel Maude. Only when her organs began shutting down did her doctors realize that she had a potentially fatal flesh-eating infection. Isabel's father, Jason, was so shaken by the experience that he quit his finance job and founded a company — named after his daughter, who is a healthy 10-year-old today — to fight misdiagnosis.

The company sells software that allows doctors to type in a patient's symptoms and, in response, spits out a list of possible causes. It does not replace doctors, but makes sure they can consider some unobvious possibilities that they may not have seen since medical school. Dr. Britto is a top executive.

Not long after the founding of Isabel Healthcare, Dr. Bergsagel in Atlanta stumbled across an article about it and asked to be one of the beta testers. So on that Monday morning, when he couldn't get the inconsistencies in the boy's case out of his mind, he sat down at a computer in a little white room, behind a nurse's station, and entered the symptoms.

Near the top of Isabel's list was a rare form of leukemia that Dr. Bergsagel had never seen before — and that often causes brown skin spots. "It was very much a Eureka moment," he said.

There is no happy ending to the story, because this leukemia has much longer odds than more common kinds. But the boy was spared the misery of pointless chemotherapy and was instead given the only chance he had, a bone marrow transplant. He lived another year and a half.

Today, Dr. Bergsagel uses Isabel a few times a month. The company continues to give him free access. But his colleagues at Children's Healthcare of Atlanta can't use it. The hospital has not bought the service, which costs $80,000 a year for a typical hospital (and $750 for an individual doctor).

Clearly, misdiagnosis costs far more than that. But in the current health care system, hospitals have no way to recoup money they spend on programs like Isabel.

We patients, on the other hand, foot the bill for all those wasted procedures and pointless drugs. So we keep getting them. Does that make any sense?

E-mail: leonhardt@nytimes.com

Correction: Feb. 28, 2006, Tuesday:

The David Leonhardt column in Business Day on Wednesday, about physicians' misdiagnoses of fatal illnesses, referred imprecisely to the medical condition of a girl named Isabel Maude. She had a flesh-eating infection, known as necrotizing fasciitis; she did not have a virus.

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When Trust in Doctors Erodes, Other Treatments Fill the Void

When Trust in Doctors Erodes, Other Treatments Fill the Void

February 3, 2006
By BENEDICT CAREY, The New York Times

A few moments before boarding a plane from Los Angeles to New York in January, Charlene Solomon performed her usual preflight ritual: she chewed a small tablet that contained trace amounts of several herbs, including extracts from daisy and chamomile plants.

Ms. Solomon, 56, said she had no way to know whether the tablet, an herb-based remedy for jet lag, worked as advertised. Researchers have found no evidence that such preparations are effective, and Ms. Solomon knows that most doctors would scoff that she was wasting her money.

Yet she swears by the tablets, as well as other alternative remedies, for reasons she acknowledges are partly psychological.

"I guess I do believe in the power of simply paying attention to your health, which in a way is what I'm doing," said Ms. Solomon, who runs a Web consulting business in Los Angeles. "But I also believe there are simply a lot of unknowns when it comes to staying healthy, and if there's a possibility something will help I'm willing to try it."

Besides, she added, "whatever I'm doing is working, so I'm going to keep doing it."

The most telling evidence of Americans' dissatisfaction with traditional health care is the more than $27 billion they spend annually on alternative and complementary medicine, according to government estimates. In ways large and small, millions of people are taking active steps to venture outside the mainstream, whether by taking the herbal remedy echinacea for a cold or by placing their last hopes for cancer cure in alternative treatment, as did Coretta Scott King, who died this week at an alternative hospice clinic in Mexico.

They do not appear to care that there is little, if any, evidence that many of the therapies work. Nor do they seem to mind that alternative therapy practitioners have a fraction of the training mainstream doctors do or that vitamin and herb makers are as profit-driven as drug makers.

This straying from conventional medicine is often rooted in a sense of disappointment, even betrayal, many patients and experts say. When patients see conventional medicine's inadequacies up close — a misdiagnosis, an intolerable drug, failed surgery, even a dismissive doctor — many find the experience profoundly disillusioning, or at least eye-opening.

Haggles with insurance providers, conflicting findings from medical studies and news reports of drug makers' covering up product side effects all feed their disaffection, to the point where many people begin to question not only the health care system but also the science behind it. Soon, intuition and the personal experience of friends and family may seem as trustworthy as advice from a doctor in diagnosing an illness or judging a treatment.

Experts say that people with serious medical problems like diabetes or cancer are least likely to take their chances with natural medicine, unless their illness is terminal. Consumers generally know that quackery is widespread in alternative practices, that there is virtually no government oversight of so-called natural remedies and that some treatments, like enemas, can be dangerous.

Still, 48 percent of American adults used at least one alternative or complementary therapy in 2004, up from 42 percent a decade ago, a figure that includes students and retirees, soccer moms and truckers, New Age seekers and religious conservatives. The numbers continue to grow, experts say, for reasons that have as much to do with increasing distrust of mainstream medicine and the psychological appeal of nontraditional approaches as with the therapeutic properties of herbs or other supplements.

"I think there is a powerful element of nostalgia at work for many people, for home remedies — for what healing is supposed to be — combined with an idealized vision of what is natural and whole and good, " said Dr. Linda Barnes, a medical anthropologist at Boston University School of Medicine.

Dr. Barnes added, "People look around and feel that the conventional system does not measure up, and that something deeper about their well-being is not being addressed at all."

Healthy and Dabbling

Ms. Solomon's first small steps outside the mainstream came in 1991, after she watched her mother die of complications from a hysterectomy.

"I saw doctors struggling to save her," she said. "They were trying really hard, and I have great respect for what they do, but at that point I realized the doctors could only do so much."

She decided then that she needed to take more responsibility for her own health, by eating better, exercising more and seeking out health aids that she thought of as natural, meaning not prescribed by a doctor or developed by a pharmaceutical company.

"I usually stay away from drugs if I can, because the side effects even of cough and cold medicines can be pretty strong," she said.

The herbal preparations she uses, she said, "have no side effects, and the difference in my view is that they help support my own body's natural capability, to fight off disease" rather than treat symptoms.

If these sentiments are present in someone like Ms. Solomon, who regularly consults her internist and describes herself as "pretty mainstream," they run far deeper in millions of other people who use nontraditional therapies more often.

In interviews and surveys, these patients often described prescription drugs as poisons that mostly mask symptoms without improving their underlying cause.

Many extend their suspicions further. In a 2004 study, researchers at the University of Arizona conducted interviews with a group of men and women in Tucson who suffered from chronic arthritis, most of whom regularly used alternative therapies. Those who used alternative methods exclusively valued the treatments on the "rightness of fit" above other factors, and they were inherently skeptical of the health care system.

Distrust in the medical industrial complex, as some patients call it, stems in part from suspicions that insurers warp medical decision making, and in part from the belief that drug companies are out to sell as many drugs as possible, regardless of patients' needs, interviews show.

"I do partly blame the drug companies and the money they make" for the breakdown in trust in the medical system, said Joyce Newman, 74, of Lynnwood Wash., who sees a natural medicine specialist as her primary doctor. "The time when you would listen to your doctor and do whatever he said — that time is long gone, in my opinion. You have to learn to use your own head."

From here it is a small step to begin doubting medical science. If Western medicine is imperfect and sometimes corrupt, then mainstream doctors may not be the best judge of treatments after all, many patients conclude. People's actual experience — the personal testimony of friends and family, in particular — feels more truthful.

To best way to validate this, said Ms. Newman and many others who regularly use nontraditional therapies, is simply to try a remedy "and listen to your own body."

Opting Out

Cynthia Riley effectively opted out of mainstream medicine when it seemed that doctors were not listening to her.

During a nine-year period that ended in 2004, Ms. Riley, 47, visited almost 20 doctors, for a variety of intermittent and strange health complaints: blurred vision, urinary difficulties, balance problems so severe that at times she wobbled like a drunk.

She felt unwell most of the time, but doctors could not figure out what she had.

Each specialist ordered different tests, depending on the symptom, Ms. Riley said, but they were usually rushed and seemed to solicit her views only as a formality.

Undeterred, Ms. Riley, an event planner who lives near New London, Conn., typed out a four-page description of her ordeal, including her suspicion that she suffered from lead poisoning. One neurologist waved the report away as if insulted; another barely skimmed it, she said.

"I remember sitting in one doctor's office and realizing, 'He thinks I'm crazy,' " Ms. Riley said. "I was getting absolutely nowhere in conventional medicine, and I was determined to get to the root of my problems."

Through word of mouth, Ms. Riley heard about Deirdre O'Connor, a naturopath with a thriving practice in nearby Mystic, Conn., and made an appointment.

In recent years, people searching for something outside of conventional medicine have increasingly turned to naturopaths, herbal specialists who must complete a degree that includes some standard medical training in order to be licensed, experts say. Fourteen states, including California and Connecticut, now license naturopaths to practice medicine. Natural medicine groups are pushing for similar legislation in other states, including New York.

Licensed naturopaths can prescribe drugs from an approved list in some states, but have no prescribing rights in others.

Right away, Ms. Riley said, she noticed a difference in the level of service. Before even visiting the office, she received a fat envelope in the mail containing a four-page questionnaire, she said. In addition to asking detailed questions about medical history — standard information — it asked about energy level, foods she craved, sensitivity to weather and self-image: "Please list adjectives that describe you," read one item.

"It felt right, from the beginning," Ms. Riley said.

Her first visit lasted an hour and a half, and Ms. O'Connor, the naturopath, agreed that metal exposure was a possible cause of her symptoms. It emerged in their interview that Ms. Riley had worked in the steel industry, and tests of her hair and urine showed elevated levels of both lead and mercury, Ms. O'Connor said.

After taking a combination of herbs, vitamins and regular doses of a drug called dimercaptosuccinic acid, or DMSA, to treat lead poisoning, Ms. Riley said, she began to feel better, and the symptoms subsided.

Along the way, Ms. O'Connor explained the treatments to Ms. Riley, sometimes using drawings, and called her patient regularly to check in, especially during the first few months, Ms. Riley said.

Other doctors said they could not comment on Ms. Riley's case because they had not examined her. Researchers who specialize in lead poisoning say that it is rare in adults but that it can cause neurological symptoms and bladder problems and is often missed by primary care doctors.

Dr. Herbert Needleman, a psychiatrist who directs the lead research group at the University of Pittsburgh, said DMSA was the pharmaceutical treatment of choice for high blood lead levels.

Researchers say there is little or no evidence that vitamins or herbs can relieve symptoms like Ms. Riley's. Still, she said, "I look and feel better than I have in years."

Life and Death

Diane Paradise bet her life on the uncertain benefits of natural medicine, after being burned physically and emotionally by conventional doctors.

In 1995, doctors told Ms. Paradise, now 35, that she had Hodgkin's disease. After a six-month course of chemotherapy and radiation, she said, she was declared cancer free, and she remained healthy for five years.

But in 2001 the cancer reappeared, more advanced, and her doctors recommended a 10-month course of drugs and radiation, plus a marrow transplant, she said.

Ms. Paradise, a marketing consultant in Rochester, N.Y., balked.

"I was burned badly the first time around, third-degree burns, and now they were talking about 10 months," she said in an interview, "and they were giving me no guarantees; they said it was experimental. That's when I started looking around. I really had nothing to lose, and I was focused on quality of life at that point, not quantity."

When she told one of her doctors that she was considering an alternative treatment in Arizona, the man exploded, she said.

"His exact words were, 'That's not treatment, that's a vacation — you're wasting your time!' " she said.

And so ended the relationship. With help from friends, Ms. Paradise raised about $40,000 to pay for the Arizona clinic's treatment, plus living expenses while there.

"I had absolutely no scientific reason for choosing this route, none," she said. "I just think there are times in our life when we are asked to make decisions based on our intuition, on our gut instinct, not based on evidence put in front of us, and for me this was one of those moments."

Cancer researchers say that there is no evidence that vitamins, herbs or other alternative therapies can cure cancer, and they caution that some regimens may worsen the disease.

But Ms. Paradise said that her relationship with the natural medicine specialist in Arizona had been collaborative and that she had felt "more empowered, more involved" in the treatment plan, which included large doses of vitamins, as well as changes in diet and sleep routines. After four months on the regimen, she said, she felt much better.

But the cancer was not cured. It has resurfaced recently and spread, and this time Ms. Paradise has started an experimental treatment with an oncologist in New York.

She is complementing this treatment, she said, with another course of alternative therapy in Arizona. She moved in with friends near Phoenix and started the alternative regime in January.

"It's 79 degrees and beautiful here," she said by phone in mid-January. "Let's hope that's a good sign."

For all their suspicions and questions about conventional medicine, those who venture outside the mainstream tend to have one thing in abundance, experts say: hope. In a 1998 survey of more than 1,000 adults from around the country, researchers found that having an interest in "personal growth or spirituality" predicted alternative medicine use.

Nontraditional healers know this, and they often offer some spiritual element in their practice, if they think it is appropriate. David Wood, a naturopath who with his wife, Cheryl, runs a large, Christian-oriented practice in Lynnwood, Wash., said he treated patients of all faiths.

"We pray with patients, with their permission," said Mr. Wood, who also works with local medical doctors when necessary. "If patients would not like us to pray for them, we don't, but it's there if needed."

He added, "Our goal here is to help people get really well, not merely free of symptoms."

That is exactly the sentiment that many Americans say they feel is missing from conventional medicine. Whatever the benefits and risks of its many concoctions and methods, alternative medicine offers them at least the promise of affectionate care, unhurried service, freedom from prescription drug side effects and the potential for feeling not just better but also spiritually recharged.

"I don't hate doctors or anything," Ms. Newman said. "I just know they can make mistakes, and so often they refer you on to see another doctor, and another."

Seeing a naturopath, she said, "I feel I'm known, they see me as a whole person, they listen to what I say."

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Despite Appearances, Science Doesn't Deny The Existence of God

Despite Appearances, Science Doesn't Deny The Existence of God

By SHARON BEGLEY
Staff Reporter of THE WALL STREET JOURNAL
January 27, 2006

Pierre Laplace didn't do science any favors when he let Napoleon provoke him.

After reading the French mathematician's opus on celestial mechanics -- the movements of planets -- the emperor asked him why the treatise, unlike the work of Isaac Newton, made no mention of God. Laplace reportedly replied, in a huff, that he had no need of that hypothesis.

Ever since, science has been saddled with the canard that it arbitrarily and a priori rules out the existence of a deity. When the Kansas board of education deleted the words "natural explanations" from the definition of science last year, it seemed like an effort to right that supposed wrong. But those who attack science as anti-God are fighting a mirage, say both secular and religious scholars.

"It is a serious error to arbitrarily insert God or the supernatural as explanations for scientific mysteries," says biologist Richard Colling of the evangelical Olivet Nazarene University, Bourbonnais, Ill. "But it is equally unjustified to claim science excludes God." As Barbara Forrest, a philosopher of science at Southeastern Louisiana University, Hammond, explains, "Science doesn't rule out anything a priori. Saying it does is false, and makes science look dogmatic."

Even to those who have never heard of Laplace, it's easy to get the idea that science starts with an atheistic, or at least agnostic, presumption. A report by the quasigovernmental National Academy of Sciences says science "is limited to explaining the natural world through natural causes." The National Science Teachers Association says science "cannot use supernatural causation in its explanations" and calls supernatural forces "outside its provenance."

Although both definitions make it sound as though science rules out the supernatural from the get-go, what actually happens is that working scientists simply find that entertaining a supernatural explanation doesn't get them very far. In that sense, argues Thomas Clark, director of the Center for Naturalism, a nonprofit educational group in Somerville, Mass., "Science doesn't presume the natural-supernatural distinction; it generates it" by dividing what works from what doesn't.

The supernatural is a dead end because science strives for testable explanations and predictions: The sun will rise in the east because Earth spins west to east, not because "God wanted it that way." Since only the most arrogant would claim the ability to predict what He will do next (and would likely be struck dead for hubris anyway), supernatural explanations fail as science. It isn't that they don't fit science's preconceptions, but that they don't get you anywhere in either deeper understanding or predictive power.

"What science is is settled methodologically," says Prof. Forrest. "It's not that science rules out the supernatural as a precondition. But scientists want to apprehend the world, and there is no procedure for studying the supernatural. God is not a controlled variable."

Although science can consider any hypothesis, natural or supernatural, a scientist who entertains the possibility of the supernatural will quickly reach a dead end. Consider the hypothesis, "Angry gods make volcanoes erupt." It doesn't get you anywhere -- not predictively (how do you know when a god will be mad?) and not mechanistically (how does the angry god make lava and gas explode out of the volcano?). Including unspecifiable processes doesn't advance understanding. As a classic Sidney Harris cartoon showed, the explanation "then a miracle occurs" doesn't cut it.

"Unless you specify the agent, its purposes and characteristics, it's an explanatory dodge," says Mr. Clark. "Agents have to be described specifically enough to be verified."

That includes specifying when and how a supernatural agent intervenes in nature. If you want to credit the supernatural with designing human beings, for instance, you have to specify why it built in autoimmune diseases, put remnants of old viral DNA in our genes, spliced in repetitive breakage-prone DNA that causes awful diseases, and took away one enzyme in the biochemical pathway that makes vitamin C but left the rest to hang around uselessly. "Working in mysterious ways" falls short. A scientific explanation must account for why one thing happens and another doesn't.

Prof. Colling, a lifelong Christian, argues that foregoing supernatural explanations "should not bother religious folks. God is not a micromanager." Explaining wondrous phenomena naturally "expands our comprehension of the created order." None of this is to deny the supernatural, just to say that it doesn't work in science. Students "are being told that they must choose between scientific reality and God," he says. "Nothing could be further from the truth."

If scientists ever bring the supernatural into science by specifying how it works and predicting what it will do next, the result may not be to the liking of those pushing for science to include God. The supernatural "will then generate reliable, predictive knowledge," notes Mr. Clark, and become just another explicable, predictable force of nature, stripped of its awe and mystery.

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Most Cough Medicines Don't Do a Thing -- Here's What Works

Most Cough Medicines Don't Do a Thing -- Here's What Works

By TARA PARKER-POPE
Staff Reporter of THE WALL STREET JOURNAL
January 10, 2006

Every year consumers spend billions on cough medicines, but a new report from the nation's top chest doctors says many of them don't work.

The finding was issued by the American College of Chest Physicians as part of its comprehensive guidelines for dealing with various forms of cough. The doctors group reviewed numerous medical studies evaluating cough preparations and concluded that many of the key ingredients in popular cough and cold medications simply aren't effective in quieting coughs caused by the common cold.

But there was good news as well. The group concluded that the ingredients found in certain older allergy medications and pain relievers are actually far more effective against cough, even though they aren't marketed as cough treatments.

Among other findings, the group concluded that the drug guaifenesin -- an expectorant found in popular brands such as Wyeth's Robitussin and Mucinex from Adams Respiratory Therapeutics in Chester, N.J. -- is ineffective in curbing cough caused by the common cold. The drug is supposed to work by thinning the mucus and making it easier to cough up phlegm. But among four studies evaluating guaifenesin compared with a placebo, two studies showed benefit while two showed no improvement. As a result, the panel concluded there isn't enough evidence to support its use to help cough caused by colds.

The panel also considered two popular cough suppressants, codeine and dextromethorphan, which potentially work by quieting the brain's cough center. Although the drugs may be effective against certain types of coughs -- like those associated with cancer -- these drugs don't work against cough due to colds, says Richard Irwin, professor of medicine at University of Massachusetts Medical School in Worcester, Mass., and editor in chief of the ACCP guidelines. In addition, codeine, even in large doses, hasn't been shown to work on cough due to a common cold, says Dr. Irwin.

Wyeth, the maker of the Robitussin line of cough products, which contain guaifenesin and dextromethorphan, says the group's findings run counter to conclusions by the Food and Drug Administration, which found the ingredients to be both safe and effective during a sweeping review of over-the-counter cough and cold remedies more than a decade ago.

"Robitussin has a long history of being sold, and it has a loyal following of customers," says Francis Sullivan, spokesman for the Wyeth Consumer Healthcare unit in Madison, N.J. "We believe that if the product didn't work these customers wouldn't purchase it."

Dr. Irwin says one explanation for the popularity of cough remedies might be the placebo effect -- which is a positive reaction to an inactive substance that the patient believes will work. In cough studies, the placebo effect has been shown to be as high as 40%.

The Chest panel also concluded that products containing zinc also are ineffective against cough due to colds. The herb echinacea has also been shown to be ineffective against cough.

The panel did conclude that some older antihistamines -- the kind that make you drowsy -- can be effective against cough caused by a cold. The medication in the drugs that makes you sleepy is the same drug that dries up the secretions in the back of the throat that can contribute to cough. The drugs may also act on the brain center to suppress cough, although how they work isn't entirely clear.

Drugs that may help quiet a cough due to cold include diphenhydramine, the active ingredient in Benadryl, dexbrompheniramine, an active ingredient in Drixoral, and chlorpheniramine, the active ingredient in Chlortrimeton.

Drugs like Benadryl and other drowsiness-inducing antihistamines aren't for everyone. The drowsy side effect is a real concern for people who must operate equipment or drive, and men with prostate problems may suffer additional side effects, such as difficulty urinating. "People think all antihistamines are equal, but it's not the case," says Dr. Irwin.

Many newer antihistamines have been altered so as to not make patients drowsy -- a major selling point of the drugs. However, the change that makes them nondrowsy also may render them ineffective against cough, notes Dr. Irwin.

Pain relievers called nonsteroidal anti-inflammatory drugs, such as naproxen, the active ingredient in Aleve, also may help patients with cough caused by cold. In studies naproxen has been shown to decrease the severity and frequency of cough. As a result, doctors believe it's likely similar drugs, such as the ibuprofen found in Advil, might also help relieve cold-related cough. The drugs may cause stomach upset or increase risk for serious gastrointestinal problems. One study has also linked naproxen with a higher risk for heart problems, although the finding remains controversial.

While the guidelines generally dispute the notion that most over-the-counter cough remedies help coughs due to colds, there is some evidence that drugs like dextromethorphan might help other types of coughs, such as those due to bronchitis.

As a result, it's important that patients with a nagging cough seek a doctor's advice on how to best treat it. Patients also should read the label, because different versions of the same brand often contain different active ingredients. "There are medicines that do work for just about all conditions that cause cough," says Dr. Irwin. "I would think people would want to take a medicine that's got a pretty good chance of working."

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Better Final Days

Better Final Days

By Shannon Brownlee, New America Foundation
Los Angeles Times | November 26, 2005

Whenever Americans stop to think about how they want to die, most conclude that they don't want to spend their last days in a hospital bed. They don't want to be stuck in an intensive care unit unnecessarily, or hooked up to machines if they can possibly avoid it. And they do not want a lot of tests and procedures, especially painful ones, if undergoing them won't improve their chances of surviving -- or at least make their passing a little easier.

But that's exactly the sort of high-tech death thousands of elderly patients with chronic illnesses are suffering, depending on which hospital they find themselves in during the last two years of life. A landmark study, published by a team of Dartmouth University researchers in the journal Health Affairs last week, looked at the care received by Medicare recipients who died in 226 California hospitals between 1999 and 2003.

The study found huge variations in the amount of care being delivered in different hospitals to similar, chronically ill patients. Let's look first at UCLA Medical Center, a hospital that is renowned for its geriatric services. The average Medicare recipient who died there spent 19 days in the hospital during the last two years of life, 11 of them in the ICU. He saw a doctor in the hospital 52 times, and Medicare paid $71,922 for his care.

At Garfield Medical Center in Monterey Park, the average patient fared worse: He spent 23 days in the hospital, saw a doctor a whopping 92 times and cost Medicare $106,254.

But if that same patient had lived instead near UC Davis, he would have been hospitalized for just over 11 days, been in the ICU for about seven days and seen one-quarter the number of doctors for a cost to Medicare of $55,323.

Did the extra care make these chronically ill patients live longer or better? Probably not, according to a previous study by the Dartmouth team. That study, published in 2003 in the Annals of Internal Medicine, concluded that Medicare patients in higher-spending regions "receive more care than those in lower-spending regions but do not have better health outcomes."

Hospitals will correctly argue that there's no way to know ahead of time which patients are likely to recover with aggressive treatment and which are in their last few months of life. And academic medical centers such as UCLA will say they provide more care because they attract sicker patients.

But are the hospitals that are spending the most any better at helping patients get well? Most patients would agree that all those days in the hospital, doctor visits and often unpleasant tests and treatments would be worth it if it actually made a difference in the quality and length of their lives. But a growing body of research suggests that it does not. And more spending does not mean that hospitals are better at delivering proven treatments, like pneumonia vaccines or beta blockers for patients admitted to the hospital with a heart attack. In fact, patients in hospitals delivering the most intensive care were often less likely to get tests and treatments that are known to work, according to the latest California study as well as previous research.

What's more, winding up in those intensive-care hospitals may actually increase a patient's chances of dying by as much as 2% to 6%. That's because hospitals, for all their power to deliver lifesaving treatments, can also be dangerous places where every drug, every treatment, every test carries the risk of error and harm.

Americans have come to believe that more healthcare equals better health. But what these studies show is that's not always true. And as anybody who has spent time in an ICU can tell you, a lot of treatment for terminal conditions can certainly make a misery of a patient's final few weeks of life.

Certainly hospitals such as Garfield and UCLA, and the doctors who work in them, generally don't think they are delivering excess care--or that they are failing to provide needed care. But doctors and hospitals are paid more for doing more, not for doing better. They often profit from giving excess care and lose money when they provide some kinds of care that really makes a difference, such as monitoring a heart failure patient once he goes home.

Those who study healthcare also note that the supply of medical resources -- not how sick the patients are -- often determines what care patients get. The more beds a hospital has, the more patients will be hospitalized, and the more MRI machines a hospital buys, the more scans will be ordered. And as much as Americans like being able to see their specialists, having more specialists involved can complicate care.

How can this problem be fixed? Patients and their distraught families cannot possibly be expected to decide what kind of care is appropriate. It's up to insurers, Medicare and Congress to restructure the financial incentives to make sure that good care pays.

Whenever payers begin talking about cutting costs, Americans begin worrying about rationing. It would be rationing if hospitals or insurers were to withhold effective care in order to save money. This isn't about denying elderly patients treatment that could help them; it's about not inflicting expensive treatments that aren't likely to improve or substantially prolong their lives.

Before Americans broach the topic of rationing, we ought first to make our hospitals deliver better care more efficiently. If every hospital in the country were to hit the benchmark of those that keep unneeded care down and quality up, it would reduce Medicare costs by 30%.

The Dartmouth group is working on a similar study of hospitals across the nation. Acting on its findings could go a long way toward averting the fiscal train wreck that is facing Medicare in the next 50 years, when costs are projected to rise to $2.67 trillion. It might also make the end of life a little easier for millions of Americans.

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Myth: Hospitals Keep You Safe from Germs

Myth: Hospitals Keep You Safe from Germs

Hospital Infections Kill Tens of Thousands Every Year

ABC News
Oct. 14, 2005

There's a deadly threat hiding inside America's hospitals. What's even scarier, your hospital is probably keeping it a secret.

Maureen Daly's mother was a healthy 63-year-old woman when she had surgery to fix a broken shoulder. However, after being admitted to the hospital, Daly's mother got an infection that left her immobilized on a respirator. Daly was told that life-threatening germs are an inevitable fact of hospital life.

Daly was shocked. "I cannot accept that it would be a fact of life that you can walk into a hospital with a broken shoulder and leave practically dead," she said.

Her mother died four months later.

Betsy McCaughey, former lieutenant governor of New York and founder of the Committee to Reduce Infection Deaths, said, "These infections kill as many people each year in our country as AIDS, breast cancer and auto accidents combined."

McCaughey said it's secrecy that's allowed the problem to grow. "Most states have not required hospitals to report their infections, or provide that information to the public," she said.

Pennsylvania is one of only six states that has passed a law requiring the reporting of infections. Experts say public disclosure forces hospitals to reduce infection rates. Dr. Rick Shannon, chief of medicine at Allegheny General Hospital in Pittsburgh, looked at the data on patients in the hospital's intensive care units. He was stunned.

"Fifty-one percent of everyone who got these infections died. Half the people who got one died," he said. Dr. Shannon wasted no time. He gave an order to the ICU staff. Reduce hospital infections to zero -- in just 90 days.

Staff nurses said they didn't think it could be done.

But after just one week, the ICU staff identified the culprit. It wasn't a superbug -- it was the staff. And the fact they each had their own way of washing hands, changing dressings, and putting in catheters. "No one actually knew what the right way to do it was. And not knowing what the right way to do it was that all these little errors could creep in that would lead to infection," Dr. Shannon said.

Dr. Shannon and his team quickly found solutions, like putting in more hand-sanitizers and raising the head of the bed 30 degrees to prevent pneumonia. The results were unbelievable.

"Ninety days later, we went from 49 infections to zero," he said.

And the results a year later are equally impressive. Only one patient in the ICU has died from an infection.

McCaughey says it's important for the public to know about infection rates at hospitals. "The public has a right to this information. If you are going into the hospital, you should be able to find out which hospital in your area has a serious infection problem, so you can stay away from that hospital," she said. Her advocacy group is working to pass more state laws -- like Pennsylvania's -- requiring hospitals to release this data.

And McCaughey says there's a simple thing you can do to keep yourself safe from dangerous germs in any hospital.

"Ask doctors and nurses to clean their hands before touching you. If you are worried about being too aggressive, just remember, your life is at stake," she said.

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Antibiotics may not help sinus infections

Antibiotics may not help sinus infections

A study comparing the use of a placebo with the drug treatment finds little difference. Patience and over-the-counter remedies are recommended.

By Jia-Rui Chong
Los Angeles Times Staff Writer

December 5, 2007

The widespread use of standard antibiotics to treat sinus infections does not help cure patients and may harm them by increasing their resistance to the drugs, according to a study released Tuesday.

The researchers found that the percentage of patients who recovered in 10 days was about the same whether they took an antibiotic or a placebo.

"With a little bit of patience, the body will usually heal itself," said Dr. Ian Williamson, a family medicine researcher at the University of Southampton in England and lead author of the paper published today in the Journal of the American Medical Assn.

The results showed that patients should be more willing to forgo antibiotics, although they should still check with their doctors when a cold worsens into a sinus infection, he said.

Dr. Daniel Merenstein, a family physician at Georgetown University in Washington, who was not involved in the study, said the report was more evidence of the overuse of antibiotics, which has caused enormous problems with drug resistance.

More than 80% of American physicians prescribe antibiotics for sinus infections, he said. Recent studies also have shown that antibiotics are unnecessary for treating ear infections and bronchitis.

"Doctors and patients get into habits and use antibiotics," Merenstein said. "Now people know . . . we should just give supportive care," such as pain relievers and saline nasal mists.

Sinusitis is an inflammation of the sinuses that commonly develops as a complication from a cold.

Allergies can also cause sinusitis, but researchers in this study focused on cases likely to be caused by bacteria.

Bacterial cases often lead to localized pain in the face and to thick discharges from the nose, with more coming from one nostril.

In the latest study, which was funded by the British government, Williamson and his group looked at about 200 sick adults from family practice offices around southwestern England.

Of the 100 patients who took the antibiotic amoxicillin, 29% had symptoms lasting 10 or more days. Of the 107 patients taking a placebo, about 34% of patients had symptoms of a similar length. Researchers deemed the difference statistically insignificant.

Williamson surmised that the antibiotic was ineffective because it had trouble penetrating pus-filled sinus cavities. Though the researchers did not test other antibiotics, he said, they probably would fare no better because amoxicillin is considered the most appropriate drug for sinusitis.

The researchers also tested the efficacy of a nasal steroid spray called budesonide because it was thought to reduce inflammation.

The proportion of patients in the steroid group and the placebo group who had symptoms lasting 10 or more days was the same at 31%.

The researchers found that the nasal spray helped a subset of patients with milder symptoms who reported feeling less ill by day 10. Williamson said the spray probably helped in milder cases because it wasn't washed away as quickly as it was in sicker patients with more nasal discharges.

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