If you haven't been reading Dr. Ben Goldacre, you should. He is arguably one of the most interesting and important science writers working today. At a time when health journalism is clogged up with self-serving peddlers of bogus diets and magic miracle cures, Goldacre, a physician and former Guardian columnist, has made it his mission to "skewer the enemies of reason" and bring research and evidence to bear on the big — and small — health questions of our time.
Over the years, Goldacre has taken on everyone from sloppy journalists to pharmaceutical executives, vitamin proprietors, and disingenuous academics. He has illuminated the evidence, and lack thereof, behind detox footbaths, homeopathy, and ear candling. And, with every debunking, he has left behind lessons in the scientific method, epidemiology, and evidence-based medicine. His writing has changed policy and informed the public at a time when few in the media stand up for science in health.
Now, you can catch up on his fun fights with bad science in his new collected works, I think you'll find it's a bit more complicated than that. He calls the tome a "statistics toilet book," which is basically true. Here, we talked to Goldacre about the changing discourse on science in the public, where the biggest abuses of science are happening today, and what he hopes to see change in the future.
Julia Belluz: You're a busy doctor and researcher. Why did you start writing?
Ben Goldacre: I was annoyed about the pseudoscientific rubbish I saw being written in the newspapers — scare stories, quackery, dodgy government statistics, silly claims from Big Pharma — and I wanted to fight back. Along the way, I've gotten away with explaining some ridiculously complicated and nerdy stuff on the pages of national newspapers, books, and increasingly at live shows and music festivals.
JB: Going back through the collected works, it was quite clear that popular media outlets gave you space to be pretty nerdy about statistics and research methods, which is uncommon in health writing today.
BG: Editors and others have often wanted me to tone down the level of statistical detail in my writing, but I never have, and the readers slowly kept coming. I think the public want nerdy details more than many in the media realize.
I've been forced to think about this more recently, because each time a book comes out in a new country, where I'm unknown, I have to try and recreate the same niche. There are clear templates for science and health writers: you write "amazing breakthrough" explainers, or "readers health advice," you get money and plenty of dependent hypochondrical readers.
But I'm not a consumer journalist. I am not empowering you to make better decisions about your own health. I find people buying quack remedies interesting, rather than horrific. I'm using people who are trying to mislead you as examples to explain the basics of evidence based medicine, statistics, research methods, and all that. What I write is pop science, not self help.
JB: Over a decade, you've debunked everything from ear candling to the anti-vaccine movement, and poorly designed education and health policies. Have you seen any progress?
BG: I think the really big change has been the Internet. What was really frustrating when I first started writing [in the Guardian in 2003] was you would see mainstream media journalists and dodgy doctors and scientists speaking with great authority and hopelessly distorting research in a way that was dangerous and scaremongering. There was no way to talk back.
When I started writing the column I felt like I was talking back on behalf of this enormous crowd of disenfranchised nerds and nerdy doctors. Now with blogs, Twitter, and comments under articles, what you can see is everybody can talk back. On top of that, not only can people more easily find a platform to put things right when they’re wrong and also explain how they’re wrong and how to understand science better, but also anybody who is interested in something, who is sufficiently motivated and clueful, can go out and find out about it online. That’s an amazing thing. It wasn’t the case ten to 15 years ago. People now are now much more empowered to fight back against stupid stuff, and to read about interesting stuff.
JB: Vaccine denialism remains stubbornly in place. Why do you think that is?
BG: Vaccine scares are a really interesting one. They have a natural history. They come and go. And they always have and they always will. It’s such an easy focus for scaremongering because it’s an intervention given to healthy people which makes people nervous. You see same anxiety around statins and blood pressure drugs. It also makes your child cry and it hurts and it's horrible and you feel guilty.
JB: What you seem to be saying here is that it is pretty difficult to fight quacks with science?
BG: I think quacks persist for all the reasons we all already know. Why do people buy quack remedies? Ludicrously expensive moisturizing creams? I think saying they’re bamboozled is patronizing and simplistic. You’ll find it’s a bit more complicated than that. We know women buy expensive cosmetics not because they see the little molecules in white coats but for an interesting host of cultural reasons: treating themselves, demonstrating to their partners they still care. It’s a ceremonial act to yourself to say I’m worth $60. All of those are really important reasons.
It’s the same with quackery: people aren’t just buying pills because they’re bamboozled by a guy in the white coat. They are buying things because they are afraid, desperate, or lazy. Giving people a ten-point plan about how to spot bad science isn’t going to help those people because they probably don’t care about science. I don’t think you can reason people out of positions they didn’t reason themselves into.
JB: But you're the guy who got your dead cat the same certificate as a famous British nutritionist just to demonstrate how bogus her credentials were. Didn't you hope that your work would have an impact on shutting down quack enterprises?
BG: I can’t believe any of the quack-mocking activities taking place over the last 10 years have really affected their bottom lines or their total body count. I do think there was an impact on the waverers: it’s been much harder to pretend that no one really knows if homeopathy works, for example. It’s different in different countries. But [my book] Bad Science in the UK sold about half a million copies, and that’s a sufficiently large number that it’s probably quite hard for people to get away with making certain dodgy claims at dinner tables in a lot of cases. The chances of their being at least one person in the room having read Bad Science is reasonably high.
So maybe you can push forward conversations on a hyper-local level and make it more difficult for people to sit with weak sops. People go, "Well, there’s something a bit wrong. But maybe it gets mixed up with politics of being anti-corporate." The debunking made it impossible to hold that kind of fake middle position and much easier to turn that fake middle position into either, "I get and understand the science and I’m going with the science" or "I’m somebody who is so unhinged by my political or social and cultural prejudices that I’m making a standup denial of science in general."
JB: What does this irrational thinking about health suggest about the kinds of policies we should make?
BG: Well, these are all insights you can exploit to do good, rather than just flog homeopathy pills. If we really want to have a meaningful impact on population health — around diet, exercise, and obesity, say — we need to look at the evidence.
We know people want quick fixes, that they're lazy, that they'll take the path of least resistance. We also have to be honest about the public-health literature: one recurring finding, from almost all health prevention research to date, is that telling people to live healthily just doesn't work, especially not over a lifetime. We need to work with all this. Probably the most important interventions to help people lead healthy lives will involve making lifelong behaviour change easy, and lazy: if you want people to do more exercise, design cities with more paths to walk or bike to work; if you want people to change their diet, get chocolate out of school and workplace vending machines, or at least make it easier to access fruit and salad.
JB: Big Pharma, and some of the harmful impact it has had on health and science, has been another key target of yours. What are the biggest pharma boondoggles going on right now?
BG: The problems in the pharma industry are very simple, and they've been the same for decades now. It basically comes down to: badly designed trials that are rigged to give positive answers; withheld trial data; and the biased dissemination of evidence through marketing.
But all of this is only possible because my own professions, medicine and academia, have failed to implement the basic principles of evidence-based medicine properly. We could be running large randomized trials cheaply, as a matter of routine, in everyday clinical care, to find out which treatments work best — but we've failed to do so. We could be aggressively auditing the extent of withheld trial data on each treatment, to shout about what's missing — but we've failed to do so. We could invest in disseminating and implementing the evidence we have on what works best to decision makers, doctors and patients so that deceitful pharma marketing would be a peripheral irrelevance — but again, we've failed to do this adequately.
That's what I covered in my book Bad Pharma, and I think that's why responding to the book was such a struggle for industry: it wasn't a conspiracy theorist's howl at them for being evil. It was a howl at my own professions - medicine and academia - for lacking ambition, and leaving ourselves and our patients open to exploitation.
The ecosystem of evidence based medicine is a hopeless patchwork of poorly coordinated players with no real clear design, or plan, or sense of efficiency. That has resulted in tremendous loss of life, in ways that haven't been adequately recognized.
JB: You've been trying to address that problem — of the broken information architecture of medicine — with your AllTrials campaign. How's that going?
BG: The best currently available evidence shows that the chances of a completed trial being published are about 50:50, and that trials with positive results are about twice as likely to be published as trials with unflattering results. That's a disaster for evidence-based medicine, and we've known about it for 30 years.
All kinds of half-hearted measures and fake fixes have come along. The FDA Amendment Act of 2007 said all trials in the US have to post their results on clinicaltrials.gov within a year of completion, and after it came into law, people thought the problem was fixed, and fell into a complacent stupor. But there was no audit, no oversight, and when an audit was finally published we found the compliance rate was only 22 percent.
I started the ball rolling on the AllTrials campaign in 2013, after people in industry responded to the publication of Bad Pharma with, frankly, ridiculous denialism. They tried to argue that the problem of withheld trial data no longer exists, in the face of all the evidence. That's how problems persist.
The AllTrials campaign calls for all trials to be registered, with their full methods and results reported: and that means all trials, past present and future, on all uses of all currently prescribed treatments. No exceptions, no loopholes.
The past year has seen extraordinary movement: the World Health Organization, the European Commission and the US, UK and Canadian Governments have finally announced they're taking further action. Hundreds of organizations have agreed to help, including the great and good of the medical establishment. Eighty patient groups signed up in one day. We've seen changes in legislation in Europe, and changes to regulations at the European Medicines Agency. More than anything, we have seen people realizing they can't just shy away from this problem, people saying they will face up to it, and there's some fun stuff coming. We are about to announce two new projects and tools that I think will really change things, in quite a powerful way. We will see. But there is no doubt, on this issue: the culture in medicine and industry has shifted.