The Quackometer

We know it is going to be a fun year for watching Homeopaths. The fight is well and truly on for who gets to pretend to regulate the profession. The beleaguered Society of Homeopaths have today gone on the offensive for total and unyielding control.

The year started off with Prince Charles and the Foundation for Integrated Health announcing the arrival on the scene of the government backed Complementary and Natural Healthcare Council, or Ofquack. This was something of an ambush on the various factions of homeopaths. They have been fighting amongst each other, trying to poach members and accusing each other of dastardly crimes and not being true homeopaths, but on one thing they appear to be unanimous: their opposition to CNHC and 'federated regulation'. What this means is that they do not want to be regulated by non-homeopaths. Heaven forbid someone who does not 'understand' homeopathy, ever tell them what they can and cannot do.

But the CNHC know that the various groups' objections to Ofquack do not mean that individual homeopaths will object. There may well be advantages of being seen to be regulated by the Princes' organisation, not least of all that it might well be a lot cheaper then the subs that the SoH demand. So, CNHS have been ploughing on as if there is no problem and appearing in newspapers and on the radio telling the world that homeopaths are happy and ready to join.

No so fast.

Today, the Society of Homeopaths have upped their game and issued a press release to tell the world that they, and they alone, are ready to set up a single register. If the CNHC succeed, SoH may well cease to exist in a year or two. They are planning their counter attacks.

Consultation commences today on regulation of homeopaths.

The Society of Homeopaths resolves to divest regulatory framework from its membership organisation to create the UK’s first independent single register and regulatory body for homeopaths

The Society of Homeopaths, Britain’s largest professional association of homeopaths, today announced that it has begun a wide-ranging consultation as it prepares to launch the UK’s first independent single register and regulatory body for homeopaths. Following a recent meeting with the Department of Health, the Board of the 30 year old Society resolved to divest its self-regulation and governance arm from its membership and continuing professional development functions in order to create a first-class regulatory body, which will govern the professional practice of an
expanding number of homeopathy practitioners.

What this means is, at the moment, a bit confusing. First of all, what is new? SoH already have the largest single register and if it wasn't for those pesky, breakaway splitters, the Alliance of Registered Homeopaths, they would have a near monopoly. They make no mention of working with other homeopaths groups and so we must assume that it this is an initiative solely within the Society and aimed at wrong footing the CNHC. How will they get ARH splitters to join the new SoH backed register and not Ofquack? My guess is that SoH believe that ARH will fold quicker than a spineless internet service provider as soon as members stop renewing their subscriptions.

There is also the implication that they are doing this with the approval of the Department of Health. But we know we have to be dead careful with Society press releases. Things should not be taken at face value. We know that the Department of Health are planning to bankroll CNHC for the next year and so it is unlikely they are supporting both initiatives. We must assume that the Society mean exactly what they say: they had a meeting with the DoH and then they embarked on this initiative. Two unrelated facts. They might have well have said that they had a bowl of cornflakes, brushed their teeth, and then decided to divest themselves of their self-regulatory powers.

The press release then goes on to praise the high level of self-regulation within the Society of Homeopaths. Regular readers here will know how difficult that is to accept. Despite obvious, numerous and well documented breaches of their code of ethics, there is little evidence of the Society ever making any adjudications and disciplining any of their members. They say in press releases that they have a "transparent complaints process". Can you find a list of their cases considered on their web site? We know complaints have been made. Where is the transparency?

So what is going to happen? Well, it looks like there is going to be a consultation,

Commenting on the Board’s resolution and the consultation process, Chair designate, Jayne Thomas said: “Today marks an important watershed in our profession. The consultation is to be widespread. We are seeking the views of patients, other homeopaths, the many colleges and universities that train the professionals, other organisations in the homeopathy field and of course politicians from all parties.

The one group that is conspicuously absent is scientists and the medical profession. And in that we see that this is one more futile bit of gesture and power politics. This is about control of the profession and not about protecting the public. My guess is that my opinion will not be welcome at this consultation.

If protecting the public was paramount then any regulatory structure must take into account the quality of advice that is given out by homeopaths. Both the CNHC and SoH want to control training standards but neither want to take on the content of that training. We know there is a deep problem within the homeopathic community that their training makes them systematically incompetent. They are trained not to recognise and actively reject normal standards of scientific evidence. They are trained to accept unquestioningly the teachings of their founder Samuel Hahnemann as if it was revealed truth. And in doing so they pose a real danger to their patients that they will offer useless or even dangerous advice, and worse, they will undermine the relationship that they might have with their GP. The failure of the Society of Homeopaths to tackle the problem of members giving out dangerous anti-malaria advice effectively rules them out as a competent body in regulating the profession.

Professor Dame Joan Higgins, who set up the CNHC, suffers from the same problem. Professor Higgins has recently given a presentation reviewing progress and expectations. One slide notes that there has been 'press criticism' that CNHC will 'endorse quackery'. Well I never! How does she respond to this criticism?

FWG role was not to evaluate the effectiveness of CAM and it did not have the capacity to do so. Its task was to establish a regulatory structure to protect the public not to promote CAM. This does not mean that it was positive/negative about CAM. It did not take a view.

This statement is somewhat disingenuous in that no one would expect them to evaluate the effectiveness of CAM, or at least homeopathy. That evaluation has already been done. Homeopathy is the ritualised prescription of plain sugar pills for all illnesses. As such, it is pure placebo and the best clinical evidence to date suggest that this is just the case. It is not a hard problem to understand. In principle, it is perfectly possible to draw up a set of regulations that take this into account.

So, Professor Higgins also washes her hands of the rather inconvenient problem that homeopathy does not work as described but practitioners are too deluded to work competently within the boundaries set by that knowledge. Whilst we have all these fighting organisations struggling to come out on top as the pretend regulators of the profession, we will have no one prepared to protect vulnerable people from homeopaths who practice their 'healing art' without care as to what is true and what is not true.

I wonder what is going to happen next?

Well, the CNHC will be late in setting up. There are already signs of slippage. There has only just been an advert go out to look for a Chair of the body. For an organisation that has stated it is ready to go in April, that looks rather late. A new chair may not be up and running until mid Summer at the earliest.

It's all going to be a complete shambles.

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Your contribution to the consulation can be made by sending thoughts to consultation@homeopathy-soh.org

Labels: Natural Healthcare Council, regulation, Society of Homeopaths

 

So, the Quackometer has been up and running for 24 hours now and most systems have been restored. A bit more to go though. For the technically inclined, this has involved a move from cuddly cotton wool children's Microsoft servers to grown up, open source, Apache/Unix servers where a missed semi-colon can kill faster than a homeopath dishing out malaria pills.

It's been a bit of a bother, but I have time in the evenings now after becoming a Wiidower. Mrs Canard Noir bought me a Wii for Christmas and I have barely used it. She is next to me hogging it at the moment, trying to get Laura Croft to shoot wolves. You should see her on Wii Boxing. It scares me.

So, I might as well blog.

Backstory: Professor Dr Professor Joseph Chikelue Obi FRCAM(Dublin) did not like some stuff I wrote that highlighted his bizarre behaviour and strange quackery. After a year or so, when the Google search results were displaying my site highly despite his best efforts to write so many third person articles about himself, he gets a professional letter writer, Ms Tanja Suessenbach, to threaten my web hosts, Netcetera, with legal action if they do not pull my site.

One would have thought they would have laughed it off. As was so beautifully put on Gimpy's Blog,

This isn’t the case of a credible individual holding a gun to the head of Netcetera in the form of a grievous and legitimate complaint it is a man in a chicken suit successfully robbing a bank while holding a giant inflatable banana and farting loudly.

But no, they asked me to remove the offending pages and 'seek agreement' with Obi. I did to avoid immediate suspension, but felt that Netcetera had put me in an impossible position of being completely unable to reach any sort of reasonable agreement with Obi. How could I? He had got what he wanted.

All I could do was dig up more info on Obi in an attempt to show Netcetera just how ridiculous he was. It was soon clear that his 'College' he set up in Dublin (Royal College of Alternative Medicine, RCAM) was a complete facade with some strange anomalies in its registration.

I wrote to Netcetera on the 30th of January,

David,

Thanks for getting back to me. I fully understand this is a difficult position for you. Netcetera want to get on with the business of web hosting rather than deal with rubbish like this. However, I feel that an important point is being missed. Obi made his claim of defamation without a shred of evidence to substantiate that. On your request, I asked for that evidence and you still asked me to take down the pages.

I hope that as a service provider you do not feel that it is acceptable for third parties to demand the removal of your customers’ content without having to back up their demand with good reasons. We will not get the evidence required to substantiate Obi’s claims.

You can see the level of Obi’s response here… http://www.professorjosephchikelueobi.com/

We have now waited long enough for either Obi or his ‘legal advisor’ to respond in a meaningful and constructive manner. That has not happened, not will it happen because his case is utterly groundless and he has achieved what he wanted to do - take down those pages. I therefore believe that it is entirely justified to re-instate
those pages and I intend to do so. I hope it will be with your consent.

Regards,

I heard nothing.

Then, last Monday, I got this email,

Thanks for your comments.

We do not wish to be in a position where we could be taken to court, and incur the loss of time and expense that would involve. Consequently Netcetera have decided to suspend the Quackometer website, with reference to our Acceptable Usage Policy, the first part of which is quoted below.

The full policy can be found on our website www.netcetera.im/SiteInfo/AUP/ “Acceptable Usage Policy This policy is subject to change, without alternate notice, so please check regularly for updates. This policy is in addition, and considered part of Netcetera’s Terms and Conditions. Netcetera will be the sole arbiter as to what constitutes a violation of this provision. 1) Web Hosting 1.1) Netcetera reserves the right to suspend or cancel a customer’s access to any or all services provided by Netcetera, where Netcetera decides that the account has been inappropriately used. Netcetera reserves the right to refuse service and /or access to its servers to anyone.”

We will prevent public access to the site as of noon today 18th February 2008. You will be able to access the content to be able to transfer it to another host if you so wish. We will hold the content available to you for 30 days, and then we will remove it from our servers.

Regards

So, that gave me 20 minutes to prepare for the collapse of the Quackometer.

On the face of it, it looks like Netcetera were unhappy about being taken to court over something that was not their argument. I think it is worse than that. If anyone there had slightly looked at the complaint (and remember, Obi and Suessenbach refused to respond to request to make clear their grievance), it would appear obvious that the complaint was groundless. Worse than that, the complaint was a blatant attempt to remove legitimate criticism from the web. Netcetera would have won and reclaimed any costs. They just did not want the bother - far easier to lose a customer than to defend their customers.

Positive Internet offered me free hosting after the Magic Watergate scandal. I had been dragging heals over this because of the large amount of work involved when I could have been harassing quacks. Positive are marvelous; you can read about them here. For me it is enough to say that they are the only Internet hosting provider with an entry on the Pilkipedia. Right now, I am aware that I have lost half my audience as they are now exploring the Pilkipedia. Damn, there goes another 50%.

So, for those of you left, I shall finish the story.

The consequences have been inevitable. Such a story spreads quickly and within hours the blogs start appearing. What is more, it starts hitting the mainstream IT sites such as ZDNet, where Rupert Goodwins starts his article by saying,

If you fancy running a controversial website, you might like to think twice before signing up with Netcetera for hosting purposes. The Duck's crime was to collate newspaper reports concerning one Joseph Chikelue Obi.
...
If you fancy doing some waterfowling of your own, do check whether your hosting contract says, as Netcetera's does, that you can be terminated without recourse and without reason. You might like to take your punt gun elsewhere.

The blogs started coming thick and fast too. No Nonsense! was one of the first of the block and described the lilly livered apology for a Web Hosting company, Netcetera. Twonilblankblank asked, "Would your webhost fuck you over?" JDC325 said, "and for all those web hosts out there, please remember: there’s a difference between defamation and criticism." Hawk/Handsaw said "Netcetera fold like a cheap suit"

The story hits the IT mainstream when a full feature makes one of the main stories of the day at El Reg. The Register reporter, Chris Williams, does some digging and phones both Netetera and Suessenbach. Netcetera do not want to play. Suessenbach tells El Reg that "We cannot speak as litigations are imminent." Scary.

Forums are now buzzing with Bad Science, UK Skeptics and the James Randi JREF covering it.

There are now way too many blogs and web pages covering this for me to mention them all (and I want to have a go on the Wii at some point). You can see a comprehensive list here. But some of my favourites are:

• Apathy Sketchpad - "Spineless Morons"
• GagWatch - "Netcetera promptly wet themselves"
• Thinking Is Dangerous - "Netcetera condemn themselves as pathetic caitiffs"
• PalMD on WhiteCoatUndergound - "What a bunch of bloody wankers!”
• Chemo Brain - "we’ll take your site off the internet if a total schmuck frightens us"
• Orac on Respectful Insolence - "outcry from the medical and skeptical blogosphere"
• MediaWatchWatch - Just check out the fantastic picture!

Other sites, such as The Bronze Blog and Paul Hutchinson’s Blog call for a boycott of Netcetera.

What does this mean? Were Netcetera right? At one level, I can sympathize with them. This is a fight they did not choose and could not gain anything from (although Positive will do well). The really big enemy is English Law that is just muddle, unfair and confused - firstly, with its heavy handed libel laws, and secondly, its inability to accommodate electronic media. A more sensible approach needs to be adopted here so that people with genuine grievances can have them heard and addresses whilst the flippant and mischievous can be harried away without fear.

But we should not let Netcetera off the hook. The fact that another host were prepeared to take me on and at their expense at least shows that it is not clear cut. For me, I had a contract with Netcetera and they broke it without giving good reason and relying on an unfair and unequal clause in their lobsided contract. Its all a bit fucked up.

And so, the last word ought to go to Mr Obi himself. What has he got to say? Well, "alighting from the back seat of an Extended Black Daimler Limousine at the start of a Whirlwind Alternative Medicine Tour", he says,

Alternative Medicine Strongman and Royal College of Alternative Medicine (RCAM) Boss, Professor Joseph Chikelue Obi , has today sent out his very best wishes to the Quackometer Blog Owner Andy Lewis, who is currently transferring his Internet Service Provider (ISP) Ports from Netcetera Ltd to Positive Internet Ltd.

That's sweet.

My fundamentally humble message to all Skeptic Internet Service Providers (out there) today is therefore extremely loud and exceedingly clear : Stop condoning the ruthless harassment of Alternative Medicine Practitioners - or be fully prepared to face the dire financial consequences of your actions !

Obi is truly a spokesperson for the whole alternative medicine movement.

Joseph, perhaps you would like to apply for this job?

Chief Executive Officer and Registrar,
COMPLEMENTARY AND NATURAL HEALTHCARE COUNCIL

£60,000 p.a. pro rata.
The new Complementary and Natural Healthcare
Council (CNHC) has been established to put in place a regulatory body for those complementary therapies which are not statutorily regulated, nor seeking statutory regulation. The main function of the new body will be to enhance public protection and confidence in the use of complementary therapists. The Council now wishes to appoint to the role of CEO/Registrar, as soon as possible.

You would certainly get my full support.

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Update 23rd Feb

From The Wardman Wire and Humaniform I learn that the presitigous Bear-Faced Usmanov Award has been made to Mr Obi for "extreme efforts in closing down websites which are criticising you by threat without evidence". Also, The Double Headed Schilling is awarded to webhosts who roll over before such threats, has naturally been given to "internet hosting (sometimes) company Netcetera."

Check out the graphics depicting these awards to Netcetera.

(Usmanov, for the uninitiated, is a Russian oligarch, and part owner of Arsenal football club, who tried to suppress ex ambassador Craig Murray from writing alegations of Usmanov's 'colourful' past by threatening ISPs with legal action. Naturally, attempts at this sort of suppression, massively amplified the exposure of the allegations. One would have thought people would learn a lesson.)

*******************************************************************************

Dr Aust sums up the mess very well on Respectful Insolence.

I hope he does not mind me reproducing it here...

Yes, the British law on this is a hopeless mess compared to the UK and Canada. The need for some sensible new legislation is clear, but British Govts are historically reluctant to do anything legislative that curtails lawyers' ability to trouser huge fees (such as in defamation lawsuits). Perhaps this is because so many British politicians are lawyers.

In the UK situation, if the plaintiff says to the ISP "this libellous thing about me is posted on your servers, take it down", then an ISP that doesn't take the stuff down becomes directly liable for the libel (Godfrey vs Demon internet). Furthermore, the longer the stuff remains up, the greater the potential libel damages "for accumulated damage to reputation" in a defamation suit - the longer the offending passage is up, the greater the potential harm to reputation, goes the reasoning. The ISPs almost certainly take the view that they are a more "attractive" libel suit target, as they are companies and hence clearly have assets, while the blog poster is likely to have no money to speak of. So the ISP has a large vested interest in caving in. This is why the "legal chill by threat to sue" types in the UK go for the ISP rather than the blogger.
All American bloggers should be duly grateful, methinks, for the judgement in Zeran vs. America Online, which effectively says "ISPs are not publishers".

In the UK, where the law conversely does see the ISP a a publisher, it comes down to whether the ISP is prepared to tolerate any potential liability, or even inconvenience, for the sake of some kind of principle.

When UCL was trying to boot David Colquhoun ff their servers following complaints and spurious libel threats, many of the people writing to the UCL Provost (including me) argued that as a University UCL had an overriding duty to protect free comment, and scientific accuracy, as part of its core purpose. But it is a bit harder to make that argument with a business or corporation, whose overriding obligation is presumably to maximize "shareholder value".

An interesting and unresolved question, with wide Internet implications, is to what extent a judgement under the silly UK law can be enforced in any other jurisdiction. In print libel cases there are suggestions that under some circumstances it can,
hence the phenomenon of "libel tourism" I referred to earlier.

You can read more Dr Aust here.

More updates (27th Feb)

The Skeptics Guide to the Universe
Rebecca Watson - The Skepchick - and Steven Novella, MD - Neurologica - discuss the Quackometer/Obi/Netcetera affair on the weekly Podcast
I hosted u a website, but I eated it
LOLquacks in an easy to understand synopsys of the Obi/Necetera Affair. A Must Read.
Quackometer vs Obi - Abusing Lawsuits to Silence Critics
Steven Novella discussed the implications of net censorship in light of the netcetera/obi affair.

Labels: BPSDB, Netcetera, Professor Joseph Obi, regulation

 

Labels: quackometer

 

The Homeopathy Research Institute (HRI) has been set up by homeopaths Alex Tournier (who apparently works for Cancer Research UK) and Clare Relton (who is based at the University of Sheffield). The Alliance of Registered Homeopaths in one of their rare press statements have made much of it. They say,

The aim of the Homeopathy Research Institute is to promote and facilitate high-quality scientific research in the field of homeopathy. The HRI will be the first central resource dedicated solely to research about homeopathy as it is practised today. A key task of the Institute will be to communicate about the science relating to homeopathy to the medical and scientific communities, the media, the general public, and to homeopaths themselves. The Institute will form a bridge between the scientific and homeopathic communities backed up by a strong PR and communications team.

The HRI itself says that its aims are to:

To perform and promote innovative research of the highest scientific standard in the field of homeopathy .

To enable and encourage communication between the scientific community, the medical profession, professional homeopaths, the media and the public at large.

This could be good news. A team of dedicated professionals who are prepared to tackle the problems of the paucity of evidence for homeopathy. Can this be true? Let's look at their first newsletter.


The first article in their newsletter says that 'It's not 'just' water'. Clearly a response to the criticisms made by sceptics like myself. So, do they demolish the obvious criticisms? Do patients get anything other than plain old water? It's not pretty...


The thrust of their argument is that 'It is hard to realise just how complex a substance water really is.' They start off by saying,

Water is everywhere; it covers 2/3 of the earth’s surface and makes up 60-70% of the human body. In our daily life, we only know water as either a liquid, ice or vapour. However upon closer inspection, scientists have catalogued 15 different types of ice, which can be admired in the intricate designs of snow flakes and the amazing pictures of water crystals taken by Dr Imoto. This complexity is due to the precise structure of the water molecule, making water one of the most complex substances known to science.

Now the fifteen types of ice have nothing to do with homeopathy. They are crystalline phases produced under enormously different conditions. They say these have been photographed by 'Dr Imoto' and so betray their first failure to stick to 'high quality'. Dr Emoto has photographed various standard ice crystals, but claims that human thought can make the pictures pretty or ugly depending on what thoughts you 'direct' at the water. This is odd given that Alex Tournier says he has a PhD in physics. Does he really believe this? Thought directed crystal growth?

Next they say,

In the field of toxicology there is a known and documented phenomenon known as ‘hormesis’. A substance showing hormesis has the property that it has the opposite effect in small doses, than in large doses. This supports the use of tautopathy, where homeopathic doses of a toxin are given to accelerate the detoxification of that same toxin.

Now, hormesis has nothing to do with water memory. Hormesis requires small doses. Homeopathy most commonly uses no doses. Central to the hormesis idea is that the same substance has beneficial effects at small doses and bad effects at large doses. Water memory requires a different agent - water structures - to play some sort of role if they existed. It has nothing to do with the doses of the substance, since there is no dose in homeopathy. Why hormesis is included to support water memory is just not clear.

Next, epitaxy:

in the field of material sciences, there is a phenomenon known as ‘epitaxis’. This phenomenon is used in the industrial manufacture of semiconductors for microprocessors. Epitaxy refers to the transfer of structural information from one substance to another, which can happen at the interface between the two substances. This transfer of structural information can remain after the original substance has disappeared from the system. This is very similar to the theory of homeopathic dilutions, the only difference being that epitaxy is known to happen in crystalline materials but not in liquids such as water.

They refute their own argument here in that epitaxy is a solid-state surface process. It cannot take place in a liquid medium. Epitaxy has nothing to do with homeopathy. I have discussed the paper quoted in support of hormesis and epitaxy at great length. Mastrangelo has to start by redefining science in order for his arguments to even start to appear to be credible.

Now, the biggest boo-boo so far,

More recently, experiments using the light emission spectrum (Raman and Ultra-Violet-Visible spectroscopy) of homeopathic water vs normal water have shown that homeopathically prepared water has a different molecular structure than normal water. Although these are preliminary results they do indicate that homeopathic remedies are not ‘just water’, something has remained of the originally diluted substance.

It is quite remarkable that for Dr Tournier, who has a PhD in physics, to think that the 'molecular structure' of water has changed. This is pseudoscience at its worst. At best, it is a bad summary of the Rao paper. But reading the Rao paper is like reading a parody of itself. It starts of by discussing the structure of water and then present its experimental evidence on ethanol.

Yes, ethanol.

As you might guess, the paper has been torn to shreds. A subsequent issue of Homeopathy published a damning critique that was not properly addressed by the authors. I fail to see how a respectful journal would not have withdrawn the paper. The letter in Homeopathy ends

It is clear that the data presented are wholly inadequate to support the authors’ assertion that UV spectroscopy can differentiate between the two remedies, and between different potencies of the remedies. If the authors wish to test their assertion it will be necessary to repeat the work from the beginning, ensuring that all samples used in the study are sourced from the same bottle of stock solvent, that all duplicate preparations for precision assessment are separately prepared de novo from the mother tinctures, and that sufficient data are generated to allow robust and valid statistical analysis of the results.

The conclusion to this review ends,

Finally, I want to return to the work of the late Dr Benveniste (1935-2004). Benveniste’s original publication in 1988 in Nature7 – science’s most prestigious journal – created outrage in the scientific community all over the world.

Why would they bring up this discredited work? The review states that "It is reassuring that his results have since then been reproduced and confirmed, showing that indeed highly (homeopathically) diluted substances retain a biological activity akin to that of the substance in its crude form". We are given two references to papers by someone by the name of Belon.

To remind us, Benveniste and the team failed to reproduce his work when a team of Nature investigators were present. Most authors retracted their names from the paper. Unfortunately, Benveniste died. Belon, one of the original authors, republished the work elsewhere. By the way, Belon is a director at Boiron, the half a billion dollar French homeopathic pharmaceutical company.

I am afraid I have to conclude that this newsletter has not been produced with the 'high quality' aims of the Homeopathy Research Institute. That is a shame. There was an opportunity for these people to assimilate and communicate the various problems with the state of research into homeopathy to their largely scientifically illiterate audience. What this newsletter looks like is little more than propaganda. I would contend that we are being offered little more than the highest pseudoscientific standards.

Labels: BPSDB, homeopathy, Homeopathy Research Institute

 

Double Blind Randomised Controlled Trials (DBRCTs) are not the preserve of medical science. Increasingly, corporations are using them to enter into a new world of Evidence Based Marketing where massive, continuous and automated trials are being run on us in order find out how to sell more stuff and become more profitable. What does this mean for medicine and our lives?

Our beliefs are our internal models of the outside world that help us inform decisions. When faced with a need for action we must have beliefs about what our goals are, how valuable those goals are, the chances of succeeding in moving towards those goals when taking a particular action and what are the consequences of failure. Our brain is calculating what our 'next best action' is so that we maximise our pay back from the action. As such, having beliefs that correspond to reality helps us make good decisions. But we are not like computers where we assign numeric probabilities to our chances of success, or correctly value our goals, or estimate the consequences of failure. We most often have intuitive feels for our next best actions that may be hard to express to another person. If we become experts in a certain field though, those intuitions may be more commonly replaced with learned knowledge and we may make more conscious and explicit calculations. But completely ignoring our intuition is hard.

Doctors are faced with a constant stream of choices. At each stage of their interactions with a patient there are dozens of decisions and options that need to be analysed, prioritised and then made. Typically, only one thing can be done at a time. What is the best thing to do next with this patient given what they have told me, what diagnostic information I have available, their history and my experience? Should I wait to see how things progress and get more information? Is surgery the right option or is medication right? Which medication? Should I refer to a more specialist colleague? What risks are there in the various courses of action? What is the patient's attitude to these risks? What impact would a poor outcome have on the patient? This is complex stuff and the training required to get to the state where you can start making such decisions on your own is likely to be over a decade – maybe two. Getting it wrong can have severe repercussions.

The big change over the last few decades in medicine is that, increasingly, historical statistical evidence is being used to help inform such decisions about 'next best actions'. Before the advent of the Evidence Based Medicine movement, such decisions were largely made on experience, training and intuition. The problems of this approach were that any particular doctor can only ever achieve a certain stock of experience and training. In a career, the number of times any doctor might have seen a certain rare condition could be counted on the fingers of one hand, if at all. Even for common conditions, a doctor’s experience of various modes of treatment may well be limited. What is worse is that personal intuition and experience are subject to horrible biases, cognitive errors and delusions that make judgements very suspect. Evidence Based Medicine has added new sources of information into the decision making process in the form of pooled data from thousands of patients. We can now assign numerical probabilities to our chances of success given data on what has happened in the past. Doctors have slowly subjugated their personal intuition and experience to the collective authority of the evidence from thousands of carefully collated cases, often in the form of clinical trials.

When faced with the question ‘What is the next best action with this patient?’ a doctor can draw on the statistical evidence of thousands of cases somewhat like the one in front of her. Double-blind randomised controlled trials (DBRCTs) are now the benchmark method for providing the statistical evidence to help inform good choices. So now, an understanding of interpreting statistical data is as much a requirement of doctors as a detailed knowledge of anatomy. This change has not been smooth and is still ongoing as this development has sometimes been seen as a threat to the authority and power of the individual consultant.

Also, the medical problem of collecting the data to allow accurate predictions of outcomes can be very difficult. It is expensive, requires lots of ethical considerations and consent from many participants. There is then the difficult problem of ensuring the results can be turned into effective actions by ensuring that medical staff are made aware of the results and that they have access to these results at their point of need.

For the patients and the public, statistical evidence can be treated with suspicion. The adage that there are 'lies, damn lies, and statistics' has come to be interpreted as that 'all statistics lie', rather than 'statistics can be misused to deceive'. But, what is pretty much unknown is how deep statistical evidence is being used to affect our lives. It is not just medicine that has noticed the power of obtaining data from controlled trials in order to make better decisions. Where this sort of thinking is increasingly making the biggest impact is not in hospitals but in a marketing department near you. And they are using these techniques to the most devastating effect. There have been no big breakthroughs in mathematics that is making this happen. Rather, software is becoming cheap and easily deployable and usable by people without PhDs in statistics. Web technology allows the intelligence discovered through statistical analysis to be easily delivered and used by the companies employees and on automated web sites. Marketing departments are using sophisticated software without being aware of its underlying complexity.

Let’s look at a mobile phone company. On the face of it, a simple business. They sell you a mobile phone and a tariff and collect some money off you monthly, or through some sort of voucher scheme. However, it is now a hugely competitive business where anyone who is ever likely to own a phone probably now does (or maybe more than one). The fight is for the customer loyalty of the most profitable customers and to sell more services to them. How does a mobile phone company do this?

Imagine that you bought a mobile phone a year ago. You are now at the end of your contract and the flashy phone you acquired last year now resembles a house brick and is as trendy as acne. You are free to stop paying your line rental and jump to a new company or get an upgrade with your existing company. What should the mobile phone company do? They could email you and offer you a new, smart, sexy phone and good deal on a tariff. But, this might alert you to the fact that you are free to jump ship and get that iPhone you know you need from a competitor. Alternatively, your company could just keep quiet and hope you keep paying your bills each month at no cost to them. Upgrading your phone is expensive for the company (in the UK, handsets are heavily subsidised). Your company does not want to do this if they do not have to. But, if they do nothing, you might quietly slip away without them ever knowing. Should they contact you or not?

The answer is statistical analysis of what other customers like you have done in the past – predictive analytics. Given your age, your address, your monthly spend, the number of texts you send, your overseas calls, the amount of time you chat on the phone, your payment history, your payment method, the complaints you have made, the ring tones you download and your eye-colour, your mobile phone company can make a good guess at your likelihood to ‘churn’ – that is, up sticks and go to the competition. Moreover, it can predict how much you might spend next year and so work out how much it can afford to spend trying to keep you as a customer (or if it should quietly ‘let you go’.) Some customers get offered low tariffs, flashy gold plated handsets, text bundles and free insurance. Others get offered a free ringtone. Statistical analysis is deciding what you get.

But it gets more sophisticated than this. If you do happen to ring up your mobile phone call centre, the complete experience, second by second, will be decided by propensity analyses to decide the ‘Next Best Action’ at every stage of the call. Do you get directed to a real agent or put in the queue for the dreaded speaking machine? Which agent will speak to you? How old will the agent be? Will they support the same football team or like the same soaps? What will that agent say to you? Every sentence the agent says will have a computer suggesting the next best thing to say. Do they offer you a phone upgrade? Ask you to pay by Direct Debit? Offer you a deal on home broadband? Agents may not have to ask you these things, but they will quickly learn their bonuses improve if they do. Computers are whirring away in the background constantly re-evaluating what is the next best thing to do. If you happen to owe your mobile phone company money on a bill, you can bet you will have been sent to one of their specialist 'collections' agents who will be following strategies suggested by the computer to get you to promise to pay.

Frequently, sufficient historical data is not available to make accurate predictions about how you will behave. In comes real-time adaptive controlled trials. When the companies next best actions are being enacted, your responses are being collected and recorded. In the background, software is running an experiment to work out what to do in the future. The software creates experiments, assigns strategies, and randomly splits the customer base into experimental groups and control groups without any human being aware who is in what group. The software is counting response types in real time and adjusts its next predictions in response to what is happening right now. A competitor might bring out a new special offer. The software recognises that certain customer ‘treatments’ are no longer quite so effective and so quietly drops certain offers, or reserves them for the most ‘price insensitive’ customers. All this could happen within hours and without a real marketeer lifting a finger. The management are no longer deciding how to market what to which customers. They are simply defining corporate strategies, such as their profitability goals or the extent of their customer base, and the statistical analysis software is quietly getting on with the job of deciding who to offer which products and when to do it. Call centre agents are none the wiser that the strategies they are using on their callers are slowly and continuously changing as the evidence base for their effectiveness is evolving.

And it is not just the call centre – the adverts that appear on your tailored personal banking web site, the leaflets that go in your statement and the promotional text messages you receive are all part of a unified and optimised strategy that is unique to you based on the vast amount of data that the company has on you, and, moreover, it is based on the evidence of effectiveness of hundreds of thousands of previous interactions with similar customers. Most often, a company will decide that their next best action is to do nothing; they know that bombarding you with silly sales messages just annoys you. The 'Old Company' sends you a hundred leaflets knowing that less than 1% will hit a receptive target and that the rest are actually doing the company harm. But without predictive capability, it has no choice. The trick is to know when that sales message will hit a chord. The beliefs that inform companies when is the best time to sell to you are no longer held in the intuitive minds of the marketing department but in the coefficients of predictive models in a computer.

Is this happening right now? It is getting very close. Scenarios like these are happening in the majority of large consumer companies. They are learning how to use the various strands of these technologies and deploying more and more. John Wanamaker, the department store owner famously said, "Half the money I spend on advertising is wasted; the trouble is I don't know which half." If he was only wasting half, then he was doing well. We are now witnessing the emergence of Evidence Based Marketing where Wanamaker's maxim will be laid to rest. Companies are talking about Enterprise Decision Management where the technologies required to do this are brought together into a central decision hub that is used to ensure the myriad of tiny and large decisions that are being made day-to-day are manageable, understandable, controllable and based on evolving evidence.

The most aggressive mobile phone companies are starting to behave just like this example, and others are following suit. It is not just phone companies, but your cable TV company, your bank and your electricity supplier. Any large company not doing this in five to ten years time will not be a company. Already, some of the largest banks are making billions of next best action decisions per year using this sort of strategy. It is not just the big decisions, such as whether to lend you money, but thousands of tiny decisions such as to ask you whether the company has your correct home phone number or your cable company to remind you that a blockbuster film you might enjoy is on tonight. Your total commercial experience will be determined by the results of thousands of double-blind randomised controlled trials, and you will be taking part in a dozen more trials, right now, without you even knowing. We are all now consumer lab rats.

For the consumer, the experience may not always be positive. Some may feel that their company appears to ‘know what they want’. Others may feel locked out of good deals. We are allowing this technology into our lives without us really thinking about it. Amazon tells you what is the next best book to buy and what music you will like. Google displays adverts that have trial-based evidence behind them to suggest you might click on them. Your Internet dating site is telling you who your next best lover is. The songs you listen to, the books you buy and the news you read is all personally decided on a ‘demographic of one’ and may well be unique to your own tastes, buying habits, politics and preferences, and all decided by statistical analyses of huge numbers of people. Sophisticated customers know this and play this to their advantage. If you are not threatening to leave your mobile phone company next time your contract is up you will not be passed to their ‘retention team’ and so will be denied the best deals. Complain too much though, and your mobile phone company (or, actually the underlying software) will decide you are not worth the bother. It’s going to be a battle. Expect consumers to retaliate, or at least, expect other start-up companies that use even more statistical evidence to help you retaliate and get the best deals. When should you buy that easyJet ticket or book that holiday? Do you know when it will be the cheapest without risking that it will sell out? Expect someone to help you soon. The First Consumer Statistics War is beginning.

Our reaction to this technology might be horror. It is impersonal and diabolical. Its advocates claim that it is just making large companies more like your local butcher who knows your name, knows you like smokey rindless bacon and you are good for credit. The reality is that it is a bit of both: a dehumanisation that makes the experience somewhat more personal. It really is just a massive extension of what your butcher does: he is nice to you and knows you well, so that he get the most out of you without you feeling cheated or exploited and start shopping elsewhere. Both you and your butcher feel happy with this arrangement.

How will this affect the relationship you have with your doctor? Well, I doubt it will be quite so brutal or extensive - just yet. The main difference is that it is not solely the doctor deciding what the desired outcomes are. The key word is 'best' in Next Best Action. Who says what is best? In corporations, they set their own goals depending on corporate strategy: number of customers, profit per customer, quarterly sales targets, etc. You have no say. With the doctor, their emerging role is to help you decide where you want to end up given the various risks and benefits of various courses of treatment. Would surgery risk curtailing your mobility, hobbies and family life? Would it be better to look at other therapies right now? Part of the doctor’s job is to help patients understand the statistical nature of what might happen. As the homeopaths are so fond of telling us, treatments must be individualised, but it is evidence based medicine that can really help individually tailor those paths of action using a good understanding of the risks and benefits of each path and your personal goals.

As I said earlier, one of the difficult problems of evidence based medicine is turning the currently available evidence into actions. It is a real problem to get the data to the doctors at the right time and the right place and in a form that can be used to help make informed decisions. Maybe doctors may learn something from their ruthless commercial colleagues. It may never happen they we see doctors simply following scripts from a computer (with the possible exception of hugely complex and time-pressured emergency and intensive care), but computers will be at hand to provide the most up to date evidence base for various courses of action. Unlike commercial data, the collation of vast amounts of health data to help in this process may not be easy. Even collecting anonymised data to help produce rolling ‘real time experiments’ is fraught with ethical and technological difficulties. The rewards are real. Statistical technology has the potential to offer us better and faster diagnosis, clearer understanding of treatment options and higher chances of favourable outcomes.

Medicine is undoubtedly moving in this direction and our reaction to it will be interesting. Already, dissatisfaction with a doctor is one of the key reasons why people turn to alternative medicine. Will the perception of increased impersonality made by the presence of computer aided consultations push people further into the arms of quacks? Will the irony of improved diagnosis and treatment plans risk people seeking unproven and dangerous alternatives?

Whatever happens, I think the emerging and defining difference between conventional health care and quackery will be the role of statistical data in helping to determine the next best actions for patients. Nowhere is this starker than how homeopaths deal with evidence in their practice. Homeopathy, if it survives, will become a living museum of what medicine used to be like before statistical data was used to help determine actions. Paternal and ineffective, but personable. Homeopaths use their ‘experience’, their 'training', their intuition, and their bible – the Organon. No homeopath ever uses the statistical data from a trial to determine which remedy to prescribe. What homeopaths end up using is their delusions and wishful thinking. In fact, the resistance to evidence in homeopathy is overwhelming and defining. For someone wishing to maintain their health, their next best action might be to ignore those not using statistics to decide their next best action.

Labels: evidence based medicine

 

After yesterday's raids by the MHRA on suspect dodgy pill sellers and their 'Internet Day of Action', perhaps one of the largest profiteers from such schemes will get away with it.

Google has been quite happy to take money from triamazon.com to show adverts for the site and the hugely overpriced food supplement pretending to be a miracle cancer cure.

This is despite the fact that Google has a clear policy that it will not do such things. As part of its advertising terms it says that it will not take adverts for:

Miracle Cures
Advertising is not permitted for the promotion of miracle cures, such as 'Cure cancer overnight!'

Furthermore, by taking money for such adverts, Google will be in contravention of the Cancer Act of 1939 which says,

No person shall take any part in the publication of any advertisement—

containing an offer to treat any person for cancer, or to prescribe any remedy therefor, or to give any advice in connection with the treatment thereof

People do get prosecuted under the terms of this Act. Trading Standards have a duty to enforce it. However, as Trading Standards tend to be highly fragmented across local councils, none of them appear to want to take on the Google giant. I believe Westminster Trading Standards as their UK address is given as,

Google UK Ltd
Belgrave House
76 Buckingham Palace Road
London
SW1W 9TQ
United Kingdom
Phone: +44 (0)20-7031-3000
Fax: +44 (0)20-7031-3001

However, Westminster undoubtedly have many higher priorities making sure dodgy plumbers do not rip off senile old ladies who live on Buckingham Palace Road.

I have complained to Google before about similar issues and also to Trading Standards. Ignored, so far. Google should be policing their own noble 'do no evil' terms, and if they cannot they should be prosecuted where they flout the law. Perhaps the MHRA, as part of their Internet day of action, could tackle one of the largest advertisers on the web. Google has the power to make or break such companies. The MHRA ought to be concerned.

Labels: Google, regulation, triamazon