Be careful what you rationalize

The first few thousand years of “medicine” were pretty bad. We did figure out a few things–an herb that’ll make you defecate faster here, something to staunch bleeding there–but overall, we were idiots. Doctors used to stick leeches on people to make them bleed, because they were convinced that “too much blood” was a problem. A primitive form of CPR invented in the 1700s involved blowing tobacco smoke up a drowned person’s rectum (it didn’t work.) And, of course, people have periodically taken it into their heads that consuming mercury is a good idea.

Did pre-modern (ie, before 1900 or so) doctors even benefit their patients, on net? Consider this account of ancient Egyptian medicine:

The ancient Egyptians had a remarkably well-organized medical system, complete with doctors who specialized in healing specific ailments. Nevertheless, the cures they prescribed weren’t always up to snuff. Lizard blood, dead mice, mud and moldy bread were all used as topical ointments and dressings, and women were sometimes dosed with horse saliva as a cure for an impaired libido.

Most disgusting of all, Egyptian physicians used human and animal excrement as a cure-all remedy for diseases and injuries. According to 1500 B.C.’s Ebers Papyrus, donkey, dog, gazelle and fly dung were all celebrated for their healing properties and their ability to ward off bad spirits. While these repugnant remedies may have occasionally led to tetanus and other infections, they probably weren’t entirely ineffective—research shows the microflora found in some types of animal dung contain antibiotic substances.

Bed rest, nurturing care, a bowl of hot soup–these are obviously beneficial. Dog feces, not so much.

Very ancient medicine and primitive shamanism seem inherently linked–early medicine can probably be divided into “secret knowledge” (ie, useful herbs); magical rites like painting a patient suffering from yellow fever with yellow paint and then washing it off to “wash away” the disease; and outright charlatanry.

It’s amazing that medicine persisted as a profession for centuries despite its terrible track record; you’d think disgruntled patients–or their relatives–would have put a quick and violent end to physicians bleeding patients.

The Christian Scientists got their start when a sickly young woman observed that she felt better when she didn’t go to the doctor than when she did, because this was the 1800s and medicine in those days did more harm than good. Yet the Christian Scientists were (and remain) an exception. Society at large never (to my knowledge) revolted against the “expertise” of supposed doctors.

Our desire for answers in the face of the unknown, our desire to do something when the optimal course is actually doing nothing and just hoping you don’t die, has overwhelmed medicine’s terrible track record for centuries.

Modern medicine is remarkably good. We can set bones, cure bubonic plague, prevent smallpox, and transplant hearts. There are still lots of things we can’t do–we can’t cure the common cold, for example–but modern medicine is, on the whole, positive. So this post is not about modern medicine.

But our tendency to trust too much, to trust the guy who offers answers and solutions over the guy who says “We don’t know, we can’t know, you’re probably best off doing nothing and hoping for the best,” is still with us. It’s probably a cognitive bias, and very hard to combat without purposefully setting out to do so.

So be careful what you rationalize.

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Re Nichols: Times the Experts were Wrong

In preparation for our review of The Death of Expertise: The Campaign Against Established Knowledge and Why it Matters, I wanted to make list of “times the experts were wrong.” Professor Nichols, if you ever happen to read this, I hope it gives you some insight into where we, the common people, are coming from. If you don’t happen to read it, it still gives me a baseline before reading your book.

Nichols devotes a chapter to the subject–expert failures are, he claims, “rare but spectacular when they do happen, like plane crashes.” (I may be paraphrasing slightly.)

How often are the experts wrong? (And how would we measure that?)

For starters, we have to define what “experts” are. Nichols might define experts as, “anyone who has a PhD in a thing or has worked in that field for 10 years,” but the general layman is probably much laxer in his definitions.

Now, Nichols’s argument that “experts” are correct most of the time probably is correct, at least if we use a conservative definition of “expert”. We live in a society that is completely dependent on the collective expertise of thousands if not millions of people, and yet that society keeps running. For example, I do not know how to build a road, but road-building experts do, and our society has thousands of miles of functional roads. They’re not perfect, but they’re a huge improvement over dirt paths. I don’t know how to build a car, but car-building experts do, and so society is full of cars. From houses to skyscrapers, smartphones to weather satellites, electricity to plumbing: most of the time, these complicated systems get built and function perfectly well. Even airplanes, incredibly, don’t fall out of the sky most of the time (and according to Steven Pinker, they’re getting even better at it.)

But these seem like the kind of experts that most people don’t second-guess too often (“I think you should only put three wheels on the car–and make them titanium,”) nor is this the sort of questioning that I think Nichols is really concerned about. Rather, I think Nichols is concerned about people second-guessing experts like himself whose opinions bear not on easily observed, physical objects like cars and roads but on abstract policies like “What should our interest rates be?” or “Should we bomb Syria?”

We might distinguish here between practical experts employed by corporations, whose expertise must be “proven” via production of actual products that people actually use, and academic experts whose products are primarily ideas that people can’t touch, test, or interact with.

For ordinary people, though, we must include another form of experts: writers–of newspapers, magazines, TV programs, textbooks, even some well-respected bloggers. Most people don’t read academic journals nor policy papers. They read Cosmo and watch daytime talk shows, not because they “hate experts” but because this is the level of information they can understand.

In other words, most people probably think Cosmo’s “style expert” and Donald Trump are as much “experts” as Tom Nichols. Trump is a “business expert” who is so expert he not only has a big tower with his name on it, they even let him hire and fire people on TV! Has anyone ever trusted Nichols’s expertise enough to give him a TV show about it?

Trump Tower is something people can touch–the kind of expertise that people trust. Nichols’s expertise is the Soviet Union (now Russia) and how the US should approach the threat of nuclear war and deterrence–not things you can easily build, touch, and test.

Nichols’s idea of “experts” is probably different from the normal person’s idea of “experts.” Nichols probably uses metrics like “How long has this guy been in the field?” and “Which journals has he been published in?” while normal people use metrics like “Did CNN call him an expert?” and “Did I read it in a magazine?” (I have actually witnessed people citing margarine advertizements as “nutrition advice.”)

If anything, I suspect the difference between “normal people’s idea of expert” and “Nichols’s idea of experts” is part of the tension Nichols is feeling, as for the first time, ordinary people like me who would in the past have been limited largely to discussing the latest newspaper headlines with friends can now pull up any academic’s CV and critique it online. “The people,” having been trained on daytime TV and butter ads, can now critique foreign policy advisers…

Let’s sort “people who distrust experts” into three main categories:

  1. Informed dissenters: People who have read a lot on a particular topic and have good reason to believe the expert consensus is wrong, eg, someone involved in nutrition research who began sounding warning bells about the dangers of partially hydrogenated fats in the ’80s.
  2. General contrarians: Other people are wrong. Music has been downhill ever since the Beatles. The schools are failing because teachers are dumb. Evolution isn’t real. Contrarians like to disagree with others and sometimes they’re correct.
  3. Tinfoil hatters: CHEMTRAILS POISON YOU. The Tinfoil hatters don’t think other people are dumb; they think others are actively conspiring against them.

People can fall into more than one category–in fact, being a General Contrarian by nature probably makes it much easier to be an Informed Dissenter. Gregory Cochran, for example, probably falls into both categories. (Scott Alexander, by contrast, is an informed dissenter but not contrarian.)

Tinfoil hatters are deprecated, but even they are sometimes correct. If a Jew in 1930’s Germany had said, “Gee, I think those Germans have it out for us,” they’d have been correct. A white South African today who thinks the black South Africans have it out for them is probably also correct.

So the first question is whether more people actually distrust experts, or if the spread of the internet has caused Nichols to interact with more people who distrust experts. For example, far more people in the 80s were vocally opposed to the entire concept of “evolution” than are today, but they didn’t have the internet to post on. Nichols, a professor at the US Naval War College and the Harvard Extension School, probably doesn’t interact in real life with nearly as many people who are actively hostile to the entire edifice of modern science as the Kansas City School Board does, and thus he may have been surprised to finally encounter these people online.

But let’s get on with our point: a few cases where “the experts” have failed:

Part 1: Medicine and Doctors

Trans Fats

Artificially created trans (or partially hydrogenated) fats entered the American diet in large quantities in the 1950s. Soon nutrition experts, dieticians, healthcare philanthropists, and the federal government itself were all touting the trans fat mantra: trans fats like margarine or crisco were healthier and better for you than the animal fats like butter or lard traditionally used in cooking.

Unfortunately, the nutrition experts were wrong. Trans fats are deadly. According to a study published in 1993 by the Harvard School of Public Health, trans fats are probably responsible for about 100,000 deaths a year–or a million every decade. (And that’s not counting the people who had heart attacks and survived because of modern medical care.)

The first people to question the nutritional orthodoxy on trans fats (in any quantity) were probably the General Contrarians: “My grandparents ate lard and my parents ate lard and I grew up eating lard and we turned out just fine! We didn’t have ‘heart attacks’ back in the ’30s.” After a few informed dissenters started publishing studies questioning the nutritional orthodoxy, nutrition’s near-endless well of tinfoil hatters began promoting their findings (if any field is perfect for paranoia about poisons and contaminants, well, it’s food.)

And in this case, the tinfoil hatters were correct: corporations really were promoting the consumption of something they by then knew was killing people just because it made them money

Tobacco

If you’re old enough, you remember not only the days of Joe Camel, but also Camel’s ads heavily implying that doctors endorsed smoking. Dentists recommended Viceroys, the filtered cigarettes. Camels were supposed to “calm the nerves” and “aid the digestion.” Physicians recommended “mell-o-wells,” the “health cigar.” Some brands were even supposed to cure coughs and asthma.

Now, these weren’t endorsements from actual doctors–if anything, the desire to give cigarettes a healthy sheen was probably driven by the accumulating evidence that they weren’t healthy–but when my grandmother took up smoking, do you think she was reading medical journals? No, she trusted that nice doctor in that Camel ad.

Chesterfield, though, claimed that actual doctors had confirmed that their cigarettes had no adverse health effects:

In the 70s, the tobacco companies found doctors willing to testify not that tobacco was healthy, but that there was no proof–or not enough data–to accuse it of being unhealthy.

Even when called before Congress in the 90s, tobacco companies kept insisting their products weren’t damaging. If the CEO of Philip Morris isn’t an expert on cigarettes, I don’t know who is.

The CDC estimates that 480,000 Americans die due to cigarettes per year, making them one of our leading killers.

Freudianism, recovered memories, multiple personality disorder, and Satanic Daycares

In retrospect, Freudian Psychoanalysis is so absurd, it’s amazing it ever became a widely-believed, mainstream idea. And yet it was.

For example:

In the early 1890s, Freud used a form of treatment based on the one that Breuer had described to him, modified by what he called his “pressure technique” and his newly developed analytic technique of interpretation and reconstruction. According to Freud’s later accounts of this period, as a result of his use of this procedure most of his patients in the mid-1890s reported early childhood sexual abuse. He believed these stories, which he used as the basis for his seduction theory, but then he came to believe that they were fantasies. He explained these at first as having the function of “fending off” memories of infantile masturbation, but in later years he wrote that they represented Oedipal fantasies, stemming from innate drives that are sexual and destructive in nature.[121]

Another version of events focuses on Freud’s proposing that unconscious memories of infantile sexual abuse were at the root of the psychoneuroses in letters to Fliess in October 1895, before he reported that he had actually discovered such abuse among his patients.[122] In the first half of 1896, Freud published three papers, which led to his seduction theory, stating that he had uncovered, in all of his current patients, deeply repressed memories of sexual abuse in early childhood.[123] In these papers, Freud recorded that his patients were not consciously aware of these memories, and must therefore be present as unconscious memories if they were to result in hysterical symptoms or obsessional neurosis. The patients were subjected to considerable pressure to “reproduce” infantile sexual abuse “scenes” that Freud was convinced had been repressed into the unconscious.[124] Patients were generally unconvinced that their experiences of Freud’s clinical procedure indicated actual sexual abuse. He reported that even after a supposed “reproduction” of sexual scenes the patients assured him emphatically of their disbelief.[125]

To sum: Freud became convinced that patients had suffered sexual abuse.

The patients replied emphatically that they had not.

Freud made up a bunch of sexual abuse scenarios.

The patients insisted they remembered nothing of the sort.

Freud decided the memories must just be repressed.

Later, Freud decided the sexual abuse never actually happened, but that the repressed, inverted memories were of children masturbating to the thought of having sex with their parents.

So not only was Freud’s theory derived from nothing–directly contradicted by the patients he supposedly based it on–he took it a step further and actually denied the stories of patients who had been sexually abused as children.

Freud’s techniques may have been kinder than the psychology of the 1800s, which AFAIK involved locking insane people in asylums and stomping them to death, but there remains a cruel perversity to insisting that people have memories of horrible experiences they swear they don’t, and then turning around and saying that horrible things they clearly remember never happened.

Eventually Freudian psychoanalysis and its promise of “recovering repressed memories” morphed into the recovered traumatic memory movement of the 1980s, in which psychologists used hypnosis to convince patients they had been the victims of a vast world-wide Satanic conspiracy and that they had multiple, independent personalities that could only be accessed via hypnosis.

The satanic Daycare conspiracy hysteria resulted in the actual conviction and imprisonment of real people for crimes like riding broomsticks and sacrificing elephants, despite a total lack of local dead elephants. Judges, lawyers, juries, and prosecutors found the testimony of “expert” doctors and psychologists (and children) convincing enough to put people in prison for running an underground, global network of “Satanic Daycares” that were supposedly raping and killing children. Eventually the hysteria got so bad that the FBI got involved, investigated, and found a big fat nothing. No sacrificial altars. No secret basements full of Satanic paraphernalia and torture devices. No dead elephants or giraffes. No magic brooms. No dead infants.

Insurance companies began investigating the extremely expensive claims of psychologists treating women with “multiple personality disorder” (many of whom had so degenerated while in the psychologists care that they had gone from employed, competent people to hospitalized mental patients.) Amazingly, immediately after insurance companies decided the whole business was a scam and stopped paying for the treatment, the patients got better. Several doctors were sued for malpractice and MPD was removed from the official list of psychological conditions, the DSM-V. (It has been replaced with DID, or dissasociative disorder.)

I wrote about the whole sordid business at length in Satanic Daycares: the scandal that should have never been, Part Two, and Part Three.

(Ironically, people attack psychiatry’s use of medications like Prozac, but if anything, these are the most evidence-based parts of mental care. At least you can collect data on things like “Does Prozac work better than placebo for making people feel better?” unlike Freudian psychoanalysis, which contained so many levels of “repression” and “transference” that there was always a ready excuse for why it wasn’t working–or for why “the patient got worse” was actually exactly what was supposed to happen.)

All Doctors pre-1900

One of West Hunter’s frequent themes is just how bad pre-modern medicine was:

Between 1839 and 1847, the First Clinic at the Vienna General Hospital had 20,204 births and 1,989 maternal deaths. The Second Clinic, attended by midwives, had 17,791 birth and 691 maternal deaths. An MD’s care conferred an extra 6% chance of death. Births at home were even safer, with maternal mortality averaging about 0.5%

In that period, MDs caused about 1200 extra deaths. …

We know that wounded men in the Civil War had a better chance of surviving when they managed to hide from Army surgeons. Think how many people succumbed to bloodletting, over the centuries.

Ever wondered why Christian Scientists, who are otherwise quite pro-science, avoid doctors? It’s because their founder, Mary Baker Eddy (born in 1821) was often sick as a child. Her concerned parents dragged her to every doctor they could find, but poor Mary found that she got better when she stopped going to the doctors.

West Hunt gives a relevant description of pre-modern medicine:

Back in the good old days, Charles II, age 53, had a fit one Sunday evening, while fondling two of his mistresses.

Monday they bled him (cupping and scarifying) of eight ounces of blood. Followed by an antimony emetic, vitriol in peony water, purgative pills, and a clyster. Followed by another clyster after two hours. Then syrup of blackthorn, more antimony, and rock salt. Next, more laxatives, white hellebore root up the nostrils. Powdered cowslip flowers. More purgatives. Then Spanish Fly. They shaved his head and stuck blistering plasters all over it, plastered the soles of his feet with tar and pigeon-dung, then said good-night.

Tuesday. ten more ounces of blood, a gargle of elm in syrup of mallow, and a julep of black cherry, peony, crushed pearls, and white sugar candy.

Wednesday. Things looked good:: only senna pods infused in spring water, along with white wine and nutmeg.

Thursday. More fits. They gave him a spirituous draft made from the skull of a man who had died a violent death. Peruvian bark, repeatedly, interspersed with more human skull. Didn’t work.

Friday. The king was worse. He tells them not to let poor Nelly starve. They try the Oriental Bezoar Stone, and more bleeding. Dies at noon.

Homeopathy has a similar history: old medicines were so often poisonous that even if some of them worked, on average, you were probably better off eating sugar pills (which did nothing) than taking “real” medicines. But since people can’t market “pills with nothing in them,” homeopathy’s strange logic of “diluting medicine makes it stronger” was used to give the pills a veneer of doing something. (Freudian psychotherapy, the extent that it “helped” anyone, was probably similar. Not that the practitioner himself brought anything to the table, but the idea of “I am having treatment so I will get better” plus the opportunity to talk about your problems probably helped some people.)

Today, “alternative” medical treatments like homeopathy and “faith healing” are less effective than conventional medicine, but for most of the past 2,000 years or so, you’d have been better off distrusting the “experts” (ie doctors) than trusting them.

It was only in the 20th century that doctors (or researchers) developed enough technology like vaccines, antibiotics, the germ theory of disease, nutrition, insulin, traumatic care, etc., that doctors began saving more lives than they cost, but the business was still fraught:

Source (PDF)

Disclaimer: I have had the whole birth trifecta: natural birth without medication, vaginal birth with medication, and c-section. Natural birth was horrifically painful and left me traumatized. The c-section, while medically necessary, was almost as terrible. Recovery from natural (and medicated) birth was almost instant–within minutes I felt better; within days I was back on my feet and regaining mobility. The c-section left me in pain for a month, trying to nurse a new baby and care for my other children while on pain killers that made me feel awful and put me to sleep. Without the pain killers, I could barely sit up and get out of bed.

Medically necessary c-sections save lives, perhaps mine. I support them, but I do NOT support medically unnecessary c-sections.

The “international healthcare community” recommends a c-section rate of 10-15% (maybe 19%.) The US rate is over 30%. Half of our c-sections are unnecessary traumas inflicted on women.

In cases where c-sections are not medically necessary (low-risk pregnancies), c-sections carry more than triple the risk of maternal death (13 per 100,000 for c sections and 3.5 per 100,000 for vaginal births.) Medically necessary c-sections, of course, save more lives than they take.

Given: 1,258,581 c-sections in the US in 2016, if half of those were unnecessary, then I estimate 60 women per year died from unnecessary c-sections. Not the kind of death rate Semmelweis was fighting against when he tried to convince doctors they needed to wash their hands between dissecting corpses and delivering babies, (for his efforts he was branded “a guy who didn’t believe the wisdom of experts,” “crazy,” and was eventually put in an insane asylum and literally stomped to death by the guards. (Freudianism looks really good by comparison.)

C-sections have other effects besides just death: they are more expensive, can get infected, and delay recovery. (I’ve also seen data linking them to an increased chance of post-partum depression.) For women who want to have more children, a c-section increases the chances of problems during subsequent pregnancies and deliveries.

Why do we do so many c-sections? Because in the event of misfortune, a doctor is more likely to get sued if he didn’t do a c-section (“He could have done more to save the baby’s life but chose to ignore the signs of fetal distress!”) than if he does do one (“We tried everything we could to save mother and baby.”) Note that this is not what’s in the mother’s best interests, but in the doctor’s.

Although I am obviously not a fan of natural childbirth, (I favor epidurals,) I am sympathetic to the movement’s principle logic: avoiding unnecessary c-sections by avoiding the doctors who give them. These women are anti-experts, and I can’t exactly blame them.

At the intersection of the “natural food” and “natural birth” communities we find the anti-vaxers.

Now, I am unabashedly pro-vaccine (though I reserve the right to criticize any particular vaccine,) but I still understand where the anti-vax crew is coming from. If doctors were wrong about blood-letting, are wrong about many c-sections (or pushing them on unsuspecting women to protect their own bottom lines) and doctors were just plain wrong for decades about dangerous but lucrative artificial fats that they actively pushed people to eat, who’s to say they’re right about everything else? Maybe some of the other chemicals we’re being injected with are actually harmful.

We can point to (and I do) massive improvements in public health and life expectancies as a result of vaccinations, but (anti-vaxers counter) how do we know these outcomes weren’t caused by other things, like the development of water treatment systems and sewers that ensured people weren’t drinking fecal-contaminated water anymore?

(I am also pro-not drinking contaminated water.)

Like concerns about impurities in one’s food, concerns about vaccinations make a certain instinctual sense: it is kind of creepy to inject people (mostly infants) with a serum composed of, apparently, dead germs and “chemicals.” The idea that exposing yourself to germs will somehow make you healthier is counter-intuitive, and hypodermic needles are a well-publicized disease vector.

So even though I think anti-vaxers are wrong, I don’t think they’re completely irrational.

 

This is the end of Part 1. We’ll continue with Part 2 on Wed.

Vaccines

I’ll cut to the very predictable chase and say that I am pro-vaccines. Quite pro-vaccines. My dad had fucking Polio as a kid, and it gave him permanent nerve damage. Heck, I know people in wheelchairs from Polio. And people who’ve had other lovely diseases we now vaccinate against.

Did you know the mumps can make you infertile?

Needless to say, my kids are vaccinated.

But I also understand the anti-vax perspective. I mean, I think it’s wrong, but I understand where these folks are coming from: it is difficult to trust a medical establishment that has treated you crappily in the past.

Doctors get plenty of stuff wrong. Doctors are human, and humans make mistakes. But when your doctor makes a mistake, it can have rather severe consequences.

And somewhere around the 50s, despite some wonderful, astoundingly great advances in medicine –actually, perhaps because of those astounding advances–doctors started doing some really dumb stuff to pregnant women. Thalidomide comes immediately to mind, but we can throw in unnecessary c-sections and encouraging them to use baby formula. Maybe this all started before the 50s. Behavioralists in the 20s were writing best-selling baby care books that advised parents to never kiss their children, keep their babies on a feeding schedule, and other such crap. (We here at EvolutionistX would especially like to point out that this advice is very evolutionarily unsound.)

Well, guess what. Having an unnecessary c-section is really fucking shitty. Taking a medication that gives you a deformed kid is really fucking shitty. Baby formula is not shitty, (unless you are in the third world, and then mixing it with the local water supply is may be a really bad idea,) but it is kind of pricy.

So I understand how people can come away from all of that and say, “my god, the medical establishment is completely full of horrible, unethical, hideously painful and unnecessary interventions!” and then might look at vaccines and say, “No fucking way.” When you lose peoples’ trust, you lose their trust.

Before we go any further, I would also like to note that, IMO, epidurals are awesome. EvolutionistX does not have it out for any currently practicing doctors. A lot of the bad stuff, as I noted, was going on in the fifties. Hospital practices related to maternity and childbirth have changed a lot since then. Please, do not make any kind of medical decisions based on “well, I heard some horror stories from the 70s.”

For that matter, don’t make your vaccine decisions based on horror stories from the 70s. And for the love of god, don’t read a bunch of junk science. That shit makes my head hurt. Find a doctor or medical information you really trust, and ask them.

But please, people, let’s not have a return of Polio. Polio fucking sucks.