Ahead of his talk at this year’s Annual Conference in Cork BEN GOLDACRE shares his views on epidemiological research, the power of the internet, public engagement with science, and – Ireland’s own particular problem with bad science – fluoride.
Over the past decade, Ben Goldacre has gained a reputation as the scourge of charlatanism, big pharma and lazy journalism. He has achieved this firstly through his ‘Bad Science’ column in the Guardian, then through the book of the same name, which has sold upwards of half a million copies. More recently, he turned his attention to lack of transparency in pharmaceutical research in Bad Pharma, and he has just published a collection of his selected writing, I
think you’ll find it’s a bit more complicated than that.
Better than nothing?
While exposing shady practices and misinformed journalists could well be a full-time job in itself, Ben’s day job is actually as a doctor, and Research Fellow in Epidemiology at the London School of Hygiene and Tropical Medicine. He originally studied medicine in Oxford and London, but soon began to see flaws in the system.
“My shift to evidence-based medicine – and shouting about what’s wrong with evidence-based medicine – was partly driven by seeing how a lot of decisions we made in clinical practice were pretty arbitrary. We’ve become satisfied with the idea that what we do is better than nothing, when we should be focusing on the idea that we give the best currently available treatment in every situation for every patient.
“Delivering that requires that we gather really high quality evidence, in much larger numbers of patients, and that requires that we drive down the cost of doing trials. So we have to become much more efficient about how we gather and use evidence in everyday clinical practice.”
He points out that, for all sorts of reasons, people are very interested in health information, but that this thirst for information can be misdirected.
“Unfortunately, it all gets sublimated into silly stories – like the Daily Mail‘s ongoing philosophical project to divide all the inanimate objects in the world into the ones that either cause or prevent cancer! What I’ve tried to do is make it easier for the general public to access good quality information: not so much about what works, but more about how we know what works, about the methods.”
Relevant to how we live our lives
Ben is, unsurprisingly, passionate about his subject, and about explaining to the public why it matters.
“I co-authored a paper in the Lancet about two years ago on how we should have a GCSE in epidemiology [in the UK]. The basics of what a cohort study or a case control study looks like, what the strengths and weaknesses are, bias, randomised trials, what a systematic review is, what a meta-analysis is: that is ultimately the science behind probably a majority of health stories in the newspapers. People fall over themselves trying to find ways of making science relevant and applicable to our everyday lives, and this is an open goal. Epidemiology is immediately relevant to your own life, to your own interests, preoccupations and anxieties, to the decisions that you make for yourself about how to live. ‘This vegetable’s good for you’, or ‘that kind of alcohol is particularly bad for you’: all of that fundamentally is epidemiology research.”
So why aren’t we learning about this?
“A lot of teachers and scientists think that epidemiology is obvious – just the application of basic common sense and rationality. They think that if you understand the principle of a control in a chemistry experiment, then you’ll understand how controls should be used in case control studies or any kind of observational epidemiology paper, and actually that’s not the case. There are specific pitfalls in interpreting observational data about human populations that are the meat and drink of epidemiology and if you’ve never thought of them you wouldn’t spontaneously invent them, just from having a good common sense approach to science and evidence. That’s why I think epidemiology really suffers.
“You often come across research scientists in medicine who know an awful lot about some transporter in the surface of a cell, and they produce groundbreaking work on it, but when it comes to interpreting a bit of evidence about whether an intervention actually works or not – or whether a trial of an intervention in their field was a fair test or whether it was flawed by design – they flounder. It’s because, again, they think that interpreting trials and observational research is common sense and doesn’t require any extra pointers. That’s arrogance, and it’s dangerous.”
A lot of what Ben does is to debunk poor journalism/science stories in the media, but his own journalism career began in quite unspectacular fashion.
“I just rang the Guardian up one day! I said what I did and what I’d like to write about and they said ok.”
He has a characteristically uncompromising attitude to writing.
“Editors have intermittently said: ‘That’s a bit too nerdy. Do you think you could tone it down for a general audience?’ and I’ve always said ‘no’. It’s ok to have a wide range in newspapers. There are things that are dumbed down but there is also a space to offer more detail, for people who happen to want that.”
He admits that having more than one string to your bow certainly helps.
“There’s a certain power that comes from having two parallel careers. This way, when someone asks me to write something I don’t want to write I can say no.”
He accepts that many journalists are under pressure to produce copy, but feels that that’s no excuse for poor science or lack of research.
“I don’t think I’ve ever been particularly unfair or unkind about individual journalists, even those who have written dangerously misleading articles, but I have used them as examples to explain how journalists mislead the public.
“I happened to read a story in the newspapers yesterday – it was maybe 1,200 words long, saying new research had shown a negative effect of iPad use among toddlers – and it was impossible to establish from reading this article even what type of research had been done, and that wasn’t for a lack of space. That was for a lack of will, a lack of belief that readers would care and perhaps, for all I know, they were deliberately obfuscating the fact that it was very weak evidence because they didn’t want to undermine their story. One of the really dangerous things about the routine misuse of evidence by journalists is that you can get into a kind of ‘boy who cries wolf’ situation: because it may well be that somebody’s just found some amazingly important new finding, about the harms of technology, that I really need to know about … but it’s got to the point where you just read and think, ‘well, I wouldn’t believe that anyway’.”
Something for everyone
In recent times we’ve seen a glut of popular science programmes on television, from Stargazing Live to Mythbusters. I ask Ben if he thinks popular science is having a ‘moment’. He’s not convinced, but is very excited, on the other hand, about the role of the internet.
“I used to get very annoyed when I first started writing about these kinds of things, because I felt the mainstream media dumbs down science, so it deprives the public of access to good quality information, and by that I mean reliable information about health and stuff, but also interesting fun, cool, stimulating stuff about how stuff works. I’m much more relaxed about that now, because it’s not the only show in town anymore. If you’re somebody who wants to find out how stuff works there is so much online. You will find styles of content for every age, for every level of ability and for every character type – very serious, straight-faced stuff, and funny, irreverent stuff, and it’s just beautiful, rich and diverse, and easy to find.”
He feels that encouraging people to look online for stimulating science is more productive than some of the government-funded projects designed to inspire public engagement with science.
“I’m really not convinced that they deliver value for money, or that they deliver people into the arms of interesting nerdy stuff online in anything like a cost-effective or effective way. The public engagement with science community is infected with some very dangerous, self-serving ideologies. For example, they’re obsessed with the idea of ‘engagement’ rather than what they call the ‘deficit model’ of public science, so they say that giving people information is
wrong and disempowering and not what they’re interested in. They want scientists to listen to the public. Now that sounds great and sometimes it’s appropriate but often it means that huge amounts of money are pumped into projects which are really just methodologically very poor. For example, instead
of funding somebody to explain to the public how we use medical data to find out what works and what doesn’t, they’ll have a meeting with 12 members of the public – who are hugely self-selecting and unrepresentative – and then interact with them for three hours to try and find out what they think. That’s a particular kind of research called social science research and it’s great if it’s done rigorously, but they’re generally doing it in a rather amateurish way, under the rubric of public engagement, and that doesn’t make sense.”
Aside from his writing (and the small matter of a day job), Ben has worked in recent years to improve transparency in the way pharmaceutical companies release trial data (Big Pharma deals with this subject in detail). He is co-founder of AllTrials, a campaign by doctors, academics, funders, pharmacists, professional bodies, patients and the public, to prevent trial results being withheld. I ask how things are progressing.
“We’ve not had any more sign-ups from pharma companies [GSK has signed up to the campaign], but we are just about to launch a really interesting new project. We’re going to start building something called a trials transparency index, so we’re going to be assessing the public statements and commitments, but also the actions, of all the major drug companies. We’re going to turn that into a basic points system, publish it as an index and update it once a year. I think it will be really interesting, because audit is one of the simplest tools in medicine and we know that it helps drive up standards. You need to know where you are and how you’re doing, in order to understand where there’s room for improvement.
“One of the most interesting findings so far, which I had hoped for all along, is that pretty much all of the things that we say companies should be doing on
becoming more transparent – everything good – are done by at least one company. So when people say it’s not possible, that’s clearly wrong.”
We look forward to further updates at the IDA Annual Conference in April.
Given the recent controversies here, as groups opposed to fluoridation campaign to try to persuade public representatives that fluoride should be removed from our water supply, I ask Ben if he has a view. He’s surprised at the vehemence of the campaigning here, and thinks that this is interesting in itself.
“I think it’s a really interesting and reasonably difficult area actually. Firstly, the evidence on the benefits of fluoridation is only kind of moderately good. But the evidence on the harms of fluoridation is really pretty poor, so overall on balance I would say it makes sense to put fluoride in water.
“But I think there’s something really interesting about why people care in the first place, in particular the ‘anti’ campaigners. There are lots of things that we do in society on a whole population level, which have moderately good evidence of benefit and about which there may be evidence that suggests very very
tiny harm, but only some of them become big-ticket, emotive issues. I think there’s a really interesting discussion to be had about: why fluoride? Why do people care? Why not folic acid?”