Wednesday, December 18, 2013

Why alternative treatments are not accepted by science

It is public knowledge that alternative treatments such as homeopathy and acupuncture (and many others) are not accepted by the scientific community as having effectiveness distinguishable from placebo. It is said that these treatments do not fulfill the criteria for medicine - which is often along the lines of double-blind clinical trials (or other trials of similar level of rigor).

This is easy to say - you just check what the dictionary says about science and check what kind of results previous research has yielded, and hope that the scientific method had worked and researchers and peer reviewers haven't been too dishonest.

But what kind of explanations and ideas do practitioners of alternative treatments have about this? After all, they think their treatments work - their customers' experiences usually support this - and many would like to have their discipline recognized better, even as part of the contemporary medicine, taught at universities.
Fourteen meridians in a Chinese acupuncture chart from the 1340s (source: Wikipedia)

Can the effectiveness be confirmed?

From books, interviews and generally on the Internet I have heard and read many opinions about the position of acupuncture and homeopathy in regards to what they call "school medicine". I'm sharing some of them here.

"Can be confirmed" / "Has been confirmed"

These are based on the idea, that the treatment "works" in the traditional sense and its effect can be confirmed and the treatment could probably be part of contemporary medicine.
  1. Effectiveness could be confirmed, but global conspiracy of Big Pharma corporations is controlling the industry and will not allow alternative practitioners to compete with their lucrative business. They are twisting and possibly sabotaging results of academic studies.
  2. Effectiveness could be confirmed, but due to the bad reputation  and "unscientific" background of the treatments, serious researchers will not attempt it, fearing that they lose their reputation.
  3. Effectiveness could be confirmed, but due to so many hoaxers and unreliable practitioners, it is next to impossible to produce reliable studies on the treatments.
  4. Effectiveness could be confirmed, but the process of doing so is very long and difficult, and it will take time before we can have conclusive results.
  5. Effectiveness has already been confirmed, but the scientific community (or Big Pharma) maintains the illusion that it has not.
  6. Effectiveness has already been confirmed: the placebo effect is the real effect, it has just been misunderstood.

"Cannot be confirmed"

Explanations in this category are based on the idea that for some reason, alternative treatments are fundamentally incompatible with what is usually called contemporary medicine or empirical science.
  1. Cannot be confirmed, because they are based on unknown interactions and laws of nature.
  2. Cannot be confirmed, because they are not based on laws of nature but a spiritual and/or unphysical connection of some kind, and by definition that is outside the reach of science.
  3. Cannot be confirmed, because they treat causes of conditions, not symptoms, and are thus outside the scope of contemporary medicine (which only deals with symptoms).
  4. Cannot be confirmed, because they are tailored for each person, and treatments of different people cannot be compared in a study.
  5. Cannot be confirmed, because they do not have a common methodology which could be evaluated.
  6. Cannot be confirmed, because they are only effective in a delicate, deep practitioner-patient relationship, which makes usual double blind and randomized controlled trials impossible.
  7. Cannot be confirmed, because medicine has distanced itself from natural treatment and spirituality so much that it is simply unable to detect the effectiveness.

"Confirmation is irrelevant"

There are some who abandon the whole idea of a treatment having an effect in the traditional sense.
  1. It is irrelevant whether it can be confirmed, because customers' (patients') own assessment of their own condition is the only possible criteria of effectiveness.
Regardless of the actual effectiveness of acupuncture, homeopathy and others, I think it would be constructive to think about these explanations instead. Some of them are actually not that implausible.

It is my understanding that patients of alternative treatments practitioners are generally (very) happy with their care. They have appointments with a private practitioner who has plenty of time to discuss with the customer, ask about background of the condition, and propose different options, unlike your usual doctor at the health center who will spend the 20 minutes by picking a diagnosis from the ICD-10 manual (or ICD-9 if you are American, I'm sorry) and write a prescription of antibiotics. Thus, general happiness about the experience should not be seen as any kind of evidence about effectiveness of the treatment, even if the harsh public health experience might act as a "nocebo" - making the drug's effect lesser.

Alternative or not?

Assuming that some alternative treatments actually work - and it is apparent that most do not - it would be incredibly useful to find out which ones have potential to be studied more and possibly be introduced to the realm of contemporary medicine. However, it has been noted that there are many ways of doing acupuncture, some of them not using needles at all, so studying one practitioner might not give any insight into how others do it. Homeopathy, on the other hand, is manifested by diluted "drugs" that have consistently been shown to contain no active ingredients (which is not in contrary to the principles of homeopathy), and would be easier to study, however in homeopathy as well it has been stressed that the treatment cannot be distanced from the delicate practitioner-patient dynamic.

Meanwhile, some ordinary health products have been misleadingly labelled as homeopathic to make them more attractive to consumers - these may be a case of products that can be shown to be effective, but as they are not true homeopathic products, they do not add to the knowledge of alternative treatments.

Homeopathy has been studied at various universities (including my alma mater, University of Michigan, which even had a dedicated department for it). Many trained physicians still allege that homeopathy is about medicine in traditional sense, and can be empirically studied and its effectiveness confirmed, thus making it a "non-alternative treatment". At the same time, explanations for how homeopathy might function have been proposed (memory of water), but even if homeopathy was effective (which I doubt), its underlying mechanism would still be unknown. Some also claim that the effectiveness of homeopathy has already been confirmed many times over, but for some reason the credible results are not taken seriously.

Supporters of alternative treatments do not always seem to grasp the breadth of ideas - among the practitioners and supporters - about what the real problem is. For some, whether acupuncture of homeopathy works is just a matter of empirical science. For others, it is a spiritual matter. Thus, homeopathy, acupuncture and others thus present themselves as ambiguous, fuzzy ooze around certain misguided concepts, which explains much of the trouble they have with contemporary medicine.

Saturday, December 7, 2013

Day of Infamy - Roosevelt's humble call to arms?

On December 7, 1941 - 72 years ago - the U.S. president Franklin D. Roosevelt gave one of his most famous speeches, calling that day the "Day of Infamy", and calling all Americans to arms against Japan and its allies - namely Germany. Allies of United States had already been engaged in the war for two years at that time.

As bad as the movie was, Pearl Harbor (2001) reminded the world about Japan's attack on Pearl Harbor, naval warfare mastermind Isoroku Yamamoto's involvement in the attack, and the U.S. response, especially the Doolittle Raid. With some misguided casting and lack of realism, it still featured important parts of the action and showed the attack through the eyes of many people present there, including seamen, pilots and nurses.It also featured Roosevelt giving his famous speech.

FDR delivering the speech to U.S. Congress

If the shoe fits, wear it

I always thought Roosevelt's wording was very fitting and the speech was an inspiring call to arms (even if I never actually read the whole text). After years of non-interventionist (or even isolationist) politics, leaving its European allies without direct military support, United States was forced to join the global war, and that day - Day of Infamy - showed Americans how unprepared United States was.

Indeed, it was infamy that United States has been caught "pants down". Its naval base in Hawaii had been attacked, after the remarkable failure of U.S. intelligence left it with no warning of the impending attack. It showed how future of naval warfare was aircraft carriers with their unique and flexible power projection capabilities, not battleships that were the mainstay of U.S. fleets. At the same time, the Mitsubishi A6M Zero fighter was to earn its reputation as the most capable naval fighter in the world.

Admiral Isoru Yamamoto, bringer of infamy
From this infamy, United States would rise to a formidable opponent in the war and end up beating up Japan in the Pacific theatre, innovating in naval and other warfare and, in the end, making the only two nuclear attacks in history, threatening to destroy Tokyo next. It had gone through the dramatic circle and avenged Pearl Harbor, and naturally also fought alongside its allies in Europe and elsewhere.

Only a couple of years ago, I realized I had misinterpreted Roosevelt's words.

The other interpretation

As depicted in the film Pearl Harbor - and numerous other films and reenactments - Japanese admirals had masterminded a daring attack to Pearl Harbor Naval Base, using aircraft carriers and naval fighters to bring destruction to the U.S. Pacific fleet. It missed the U.S. aircraft carriers, which - very wisely - the planners considered the main target, because unlike Americans, they realized their potential. However, the strike itself was very successful.

To recap, Imperial Japanese Navy launched a direct attack on United States Navy's base in Hawaii. Japan attempted to abide by the Hague Convention of 1907, by announcing its intentions - declaring war - before the attack, but due to delay caused by translation of the declaration from Japanese to English, war was declared a bit after the launch of the strike.

Apparently Roosevelt - and Americans still this day - thought it was an improper way to start a war. USA and Japan had been engaged in negotiations that were hoped to alleviate any need for war, and it seemed those negotiations had been a sham to make U.S. leadership uncertain about its true intentions, and as a continuation of that, an attack withoug declaring a war first was infamous.

Infamy in another context
Even though on many fronts there were formal declarations of war in WWII - for example, the United Kingdom declaring war on Gemany in September, 1939 - often hostilities were started without warning. Germany's attack on Poland in September, 1939 was one example, Soviet Union's attack on Finland in November of that year (a surprise, after months of negotiations) was another. Unlike many others, Japan made it clear that this was about a war between sovereign nations, and its armed forces engaged the other nation's armed forces, by striking a military target, and apparently honestly tried to make a declaration of war just as international agreements stipulated.

Deception is used in diplomacy and international relations - but to call Japanese tactics "infamy" is blatant exaggeration. Indeed, Japan had malicious intent and it threatened the whole Pacific region and was friends with Germany, but in the context of Second World War, its strike on a U.S. naval base was an exceptionally honest way of starting a war, as awkward as it sounds.


Michael Bay's Pearl Harbor, the awkward reference frame of this post
During the course of WWII, whole cities - with their populations - were effectively wiped off the map, including Coventry, Dresden, Rotterdam, Hiroshima and Nagasaki. The scope of destruction a war can bring was redefined. Was the attack on Pearl Harbor more "wrong" than other military actions of WWII? Was the diplomatic deception more "wrong" than other similar tactics around that time? Was the response less infamous?

I still think the interpretation of "Day of Infamy" meaning "United States got caught pants down by Japan, and it is embarrassing" is more fitting in the context of WWII. However, it should not take away from the remembrance of December 7, 1941, which marked the start of war between USA and Japan, and as such is a day to be remembered, as yet another realization of war being inevitable, and the start of the last war between these countries.

Wednesday, December 4, 2013

Private cars vs. public transportation, an epic battle

Ground rule: use public transportation if you can. It is good for the environment and good for the city (if you are in a city) and it increases your sex appeal. However, the whole picture is much more complex than that. City planners and bus manufacturers try to appeal to the public by launching publicity campaigns like this one from the Polish bus manufacturer Solaris Bus & Coach SA:


This photo is from their Facebook page. The photo caption reads (from Google Translate):
So many cars disappear from the streets of our cities, when their owners will fill one bus. Public transportation! This number of cars would be unnecessary, if Their owners changed to a bus. Public transport!
It looks like the bus in the photo is Solaris Urbino 18 Hybrid, which is one of the manufacturer's newest products, and is a very modern hybrid vehicle. Based on the product brochure, it the densest configuration, it can carry 161(!) passengers, which is quite impressive. It looks like there are about thirty rows of private cars, five cars in a row, so let's make a wild guess and assume that there are 161 private cars on the left side of the picture. The point is clear: many private cars actually carry only one passenger, the driver, and when you fully utilize a bus, you can carry lots of people.

The good bus

How many of the 161 passengers - who now have abandoned their cars and only commute by bus - can actually have a seat? Answer: 51. Assuming that all passengers are average-sized and able-bodied, 110 of them will have to stand for the whole journey, and they cannot take any wheelchairs or a baby strollers.

It is true that number of vehicles on the right (1) is less than the number of vehicles on the left (161). The bus full of people would be much more efficient on transporting the people than the cars are, which is the point of mass transportation in general.

These publicity campaigns consistently compare the "best case" scenario for buses and "worst case" for cars, and this may lead to unrealistic expectations. In the scenario of the image, the bus will be as full as it can legally be. It probably won't be comfortable, fast or maybe not even safer than private car (there are no safety belts or air bags on buses, except for the driver). Because it is full, stops will be long and cumbersome, some people might even have to step out to let other passengers out, and then board again. The bus will also use slower and smaller roads to pick up passengers, and will usually not take the passengers to their ultimate destination - they will have to switch to another bus or walk (or use other form of transportation).

The mass transportation model works well in crowded cities for commuting, but actual occupancy rates are often much lower. According to UK Department for Transport's report, the estimated average occupancy rate (vehicle miles divided by passenger miles) of buses in London was 19.3, which is good - but only 9.1 outside of London (11.1 for the whole Great Britain). It also mentions that the current trend is that the rate for outside London is falling, potentially making mass transportation less effective and more challenging to maintain.

The bad private cars

According to University of Michigan Center for Sustainable Systems' report, average occupancy rate of all U.S. vehicles was 1.55 in 2011. The average rate varies by trip purpose - for leisure it is close to 2, for commuting it is often close to 1, and sometimes the car can also be full(!).

1.55 passengers is 31 % of a passenger vehicles maximum capacity (assumed five). 11.1 passengers is only 15.9 % of maximum capacity of a traditional city bus (40 seats and 30 standing, rough estimate). 

With these figures, you only need two or three cars to match the average occupancy rate of a bus, and with a car you can travel from point to point with greater flexibility. Fuel efficiency for new cars is more than 25 miles per gallon (sorry for using non-standard units!) and for an ordinary U.S. city bus, according to National Renewal Energy Laboratory's study, was roughly 4.0 mpg (Appendix C). 

With 11 passengers, this would equal to 44.0 passenger miles per gallon (we're talking approximations here, in reality of course fuel economy changes with the load), which is only slightly better than for a modern passenger vehicle with only 1 occupant! A full passenger vehicle would clock near 150 passenger miles per gallon (assuming no extra hurdles, heavy traffic, stops etc.) - and even with average 1.55 passengers it would still clock an impressive 38.75 pmpg.

Conclusions

Based on these numbers, driving a passenger car alone is approximately as fuel efficient as it is to travel on a bus, and with at least two passenger, it is significantly more efficient. At the same time, it is much more comfortable, flexible, faster and safer, and it allows you to transport groceries, strollers and other items.

However, this is not the complete picture either, for many reasons.

While that 4.0 mpg for a city bus is measured based on actual vehicle miles and fuel consumption, directly comparing it to passenger car fuel deficiency is difficult. Cars are used for much more than commuting, and often buses simply do not go where drivers would like to go. Often bus trip involves somebody driving a private car to pick up a passenger, because the nearest bus stop is too far away (or in a dangerous place) to walk. With newer buses (and hybrid and electric engines) efficiency can be improved - and bus is not the only form of mass transportation in many cities.

Good city and transport planning can improve public transport by planning the city around it and making it easy to catch a bus or train and switch between them. However, it may create dense suburbs without which heavy rail transport might not be worth building there.

And, perhaps most importantly, the average occupancy rate can be vastly improved. If people really would ride the bus when it is practically possible, there could be less traffic on the roads, less pollution and better fuel economy (per passenger) for buses. Owners (and drivers) of private cars are not (all) stupid. Many of them would ride the bus, subway, train or tram if it was feasible, but it is not because of bad route planning. I was unfortunate to experience this myself in 2009 when I started in a new job which was located only about 5 km from my home - but travel time there by bus was almost 40 minutes, and involved one or two switches. I bought a car (Citro├źn C1, 64.0 mpg) and haven't regretted that decision one second. (I still walked there sometimes.)

Frank Palmer of Daily Kos wrote about the "mpg fallacy" - and made some of the same points I make here. 

We will not and practically cannot achieve the utopian future where private cars have been exchanged for mass transportation - at least not in near future, and meanwhile, a more complete picture of different forms of commuting and transportation should be discussed in public. Mass transit is good, but by average not nearly as good as it is claimed to be. Sadly.

P.S. The modern hybrid bus in the image would achieve around 1000 pmpg.