Honest Universe

Superstition, pseudoscience, and scepticism

GirlGuiding New Zealand Has Removed “God” From Their Promise

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In July 2012, Girl Guides Australia changed the promise all Girl Guides have to make, by removing the compulsory mention of “God”. After seeing this news, I looked up the GirlGuiding New Zealand website to find if they had a similar compulsory mention, and found that they had.

Although I am obviously ineligible to be a Girl Guide, as an atheist I can understand how being told you have to make a promise to a god in order to become a member of a group could make one feel unwelcome. Similar to if I were asked to swear with my hand on a Bible, it would feel dishonest to do so. As such, it feels rather discriminatory, whether intended that way or not.

After seeing that Girl Guides Australia had made this change, I sent the following message to GirlGuiding New Zealand in July 2012:

To whom it may concern,

I was rather shocked to discover recently that your organisation includes in its promise (the recitation of which is apparently a requirement for membership) the words “with the help of my God”. While I commend the fact that, right after mentioning this on your site, it is specified that members of other religions may alter the wording (http://www.girlguidingnz.org.nz/what-we-do/promise-law/) to better suit their specific religion, I’m rather concerned that this seems intended to either discriminate against or actively discourage irreligiosity and atheism in your membership.

After the recent news that Girl Guides Australia have removed (http://www.abc.net.au/news/2012-07-05/girl-guides-drop-queen-god-from-promise/4113022) any compulsory mention of “God” from their Guide Promise, I’m hopeful that you might follow in their exemplary footsteps. I’ve never been given any other reason to believe that your organisation might harbour such an inappropriate agenda, and as such I fully expect that this is simply an anachronistic artifact from an old tradition. I thought I might suggest that, in light of the change made by Girl Guides Australia, you might consider that it is time for your organisation to make a similar change.

Sincerely,
Mark Hanna

A week later, I received the following response from Susan Coleman, the CEO of GirlGuiding New Zealand:

Dear Mr Hanna

Thank you for your email regarding the inclusion of the words “with the help of my god” in the GirlGuiding New Zealand promise.

GirlGuiding New Zealand, Nga Kohine Whakamahiri o Aotearoa, is an organisation for girls and young women aged 5 to 18 years old, whatever their race, religion, ethnicity or background and there is no intention of discriminating against or discouraging any personal belief. The objectives of the organisation include the development of the whole girl, promoting self-confidence and growth through fun, friendship and learning experiences in life-skills, leadership and decision-making in a safe supportive environment. An individual’s beliefs, family cultures and circumstances are respected and Guiding embraces all aspects of the diversity of New Zealand society.

At this time, there is no intention to consider changing our promise.

Regards
Susan Coleman

I didn’t find that response very encouraging, although I hadn’t expected my email alone to prompt them to change their promise. Today, 2 years later, I saw a news article with the headline GirlGuiding removes God from pledge. I’d encourage you to read the whole article, but here’s the gist:

God has been removed from the promise recited by all members of GirlGuiding New Zealand, after more than a century of being mentioned.

The move, which took place in April this year, has raised barely a ripple of dissent.

I wonder if the lack of comment may be in part due to the lack of fanfare; notice that the change was made in April but this news article was published in October. This is their new promise:

I promise to do my best,
To be true to myself and develop my beliefs,
To live by the Guide Law
And take action for a better world.

For context, here is the Guide Law:

As a Guide I will try to

  • be honest and trustworthy
  • be friendly and cheerful
  • be a good team member
  • be responsible for what I say and do
  • respect and help other people
  • use my time and abilities wisely
  • face challenges and learn from experiences and
  • care for the environment.

Particularly now that the unnecessary inclusion of a god has been removed, I think this is a great thing for young girls (and the rest of us too) to aspire to.

Well done GirlGuiding New Zealand for making this change!

Written by Mark Hanna

2014/10/17 at 5:26 pm

Ethical Pharmacy Practice 2: Time for a Spring Clean

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In July, I wrote an article on Ethical Pharmacy Practice and Homeopathic No-Jet-Lag. In it, I described the importance of the role pharmacies play in the healthcare system, and their ethical obligation not to mislead consumers or promote ineffective healthcare products. In particular, I described an advertisement I saw in an Auckland pharmacy for a homeopathic product called “No-Jet-Lag”, and the complaint I submitted to the Advertising Standards Authority about it via the Society for Science Based Healthcare. There’s also a write up of this decision and the 2 others released at the same time on the Society’s website: Pharmacy to Remove Homeopathic Product Following Complaint

On the 9th of October, the ASA released their decision to the public. They ruled to uphold my complaint, which means the advertisement has to be removed. More importantly, in response to my complaint the pharmacy made a promise to remove the product from sale if the complaint was upheld. Here’s what they said:

We believe that the manufacturer, Miers Laboratories ought to respond to the substantive complaint that it’s [sic] representations fail to comply with the Therapeutic Products Advertsing [sic] Code.

We believe that the product is sold in many pharmacies in New Zealand and it is somewhat arbitrary that our pharmacy is the subject of the complaint.

We are interested in the outcome of the complaint and can indicate that if the Authority upholds the complaint we will remove the product from sale. In the meantime, the product has been removed from the counter and placed on a less prominent position.

I agree with their first two points. While I think pharmacies shouldn’t promote or sell healthcare products without a sound understanding of the evidence behind them and the claims made about them, I also think it’s reasonable to expect the manufacturer (who also produced the advertising in this case) to substantiate the claims. Moving the display to a less prominent position in the meantime seems like a reasonable compromise as well, although of course I’d prefer it if the product were never stocked in the first place.

I also agree with them that their inclusion in this complaint is somewhat arbitrary. For that reason I am not going to specify in this article which pharmacy it was. If you really must know then you can read the full decision on the ASA’s website. As they said, many New Zealand pharmacies sell this product and I think this complaint applies to all of them.

I also think this pharmacy’s promise to remove the product from sale in the event that this complaint is upheld, as it now has been, is the appropriate response. I think that every single New Zealand pharmacy that stocks No-Jet-Lag should follow suit. There are a lot of them. The website for this product even claims on its New Zealand Retail Outlets page that “Most chemists nationwide” stock it.

As I mentioned in my original post on this topic, and in my complaint, New Zealand pharmacists are bound by the Pharmacy Council’s Safe Effective Pharmacy Practice Code of Ethics 2011. Perhaps the most important part of this industry code of ethics, at least in my mind, is section 6.9:

YOU MUST:

Only purchase, supply or promote any medicine, complementary therapy, herbal remedy or other healthcare product where there is no reason to doubt its quality or safety and when there is credible evidence of efficacy.

This is a very fine standard to adhere to, and I would hope that all businesses to which it could possibly apply would adhere to it as well, although realistically I know that’s not the case.


In response to the complaint, Miers Laboratories submitted a few studies to the ASA. They were pretty laughable though when you look at the sample size:

In all our research we base our work on previous studies, the first study for jet lag used 5 people, then it was 10 and at the time the accepted worldwide minimum was 12 for clinical trialOur [sic] bigger study used 19 people.

So basically “most of our studies didn’t even meet the very low minimum accepted size, and even the largest one was tiny”. Very impressive, Miers Laboratories.

The 19 person study they mention is also promoted on their website, and I pre-emptively discussed it in my complaint. It seems the Advertising Standards Complaints Board essentially agreed with my criticisms:

The majority of the Complaints Board said the statement “It really works” was an absolute therapeutic claim and, as such, required a high level of support. However, it noted the trial population in the pilot study was small, the methodology was not robust and the results had not been published or peer reviewed. The Complaints Board also noted the study was an in-house trial conducted by the Advertiser rather than independent research.

Given the weaknesses in the study, the majority of the Complaints Board said the Advertiser had not satisfactorily substantiated the claim the product “really works” and, as such, the Complaints Board said the advertisement had the potential to mislead consumers. Consequently, the Complaints Board said the advertisement did not observe a high standard of social responsibility required of advertisements of this type. Therefore, the majority of the Complaints Board ruled the advertisement was in breach of Principles 2 and 3 of the Therapeutic Products Advertising Code.

For context, Principle 2 of the Therapeutic Products Advertising Code states that:

Advertisements must be truthful, balanced and not misleading. Claims must be valid and have been substantiated.

And Principle 3 states that:

Advertisements must observe a high standard of social responsibility.

This is basically exactly the result I was hoping for, which is great. However, I was a little concerned by one part of the decision:

A minority of the Complaints Board disagreed [that the advertisement was in breach of Principles 2 and 3 of the Therapeutic Products Advertising Code]. It acknowledged the study sent by the Advertiser to support its claims. While it noted the issues with the study, the minority of the Complaints Board was of the view the product was not harmful and said the consequences of the product not working were not significant or serious for the consumer.

I’d expect anyone who has ever paid money for a pill to prevent jet lag would disagree with this, although it is obviously a lot more serious than something like a cancer treatment that doesn’t work. More importantly, although I do agree that it’s important to consider the severity of what happens if the product doesn’t work, I hope that the ASA will not give a free pass to misleading therapeutic advertising simply because it’s for a condition that they deem insignificant.


Now that this complaint has been upheld, the pharmacy in question has promised to remove No-Jet-Lag from sale. I hope this is the start of a spring clean for all New Zealand pharmacies that stock this product. They should follow this responsible example and take the opportunity to examine other products they have for sale – especially homeopathic products – to ensure that they are abiding by their ethical duty not to promote or supply healthcare products for which there is no credible evidence of efficacy.

You can help. Next time you see a homeopathic product in a pharmacy, ask them what the evidence for it is. If you see this particular product, ask them if they’re aware that the Advertising Standards Authority upheld a complaint against it on the basis that the evidence for it just isn’t good enough.


EDIT 2014/10/12

It’s great to see that several media outlets have picked up this story:

Movement of the Moon

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If you were up late last Wednesday, you’d have gotten the chance to watch the second total lunar eclipse this year. A lunar eclipse occurs when the Earth moves directly between the Moon and the Sun, therefore blocking the light to the Moon and making it turn dark.

This is very cool to watch, especially if you get a good look at the Moon during totality, when it is in the darkest part of the Earth’s shadow known as the umbra. At this point, the only sunlight reaching the Moon is that which is refracted through the Earth’s atmosphere. For the same reason as why sunrises and sunsets appear a lovely reddish colour, this light is also quite red, and as the Moon reflects some of this light back at us it appears a dim bronze colour.

This is one of my favourite space facts, and I find it quite poetic – you’re looking at the reflected light of all the sunrises and all the sunsets in the world, all at once. There are many spectacular photos of this effect online if you care to search for them too. But this is not what I want to write about in this article.

If you were watching Wednesday’s eclipse from Auckland, as I was, you’d probably have been disappointed to see that it was quite cloudy for the duration of totality. However, you were probably able to get a good view of the first part of the eclipse, when the Moon is moving into the outer part of the Earth’s shadow known as the penumbra.

Greg O’Beirne managed to put together a great compilation of this part of the eclipse:

Photo by Greg O'Bierne

Photo by Greg O’Beirne

As you can see, it looks rather like the Moon is having a bite taken out of it. In this compilation the position of the Moon is held roughly constant but in reality it’s the Moon that is moving here. During a lunar eclipse, we are given the rare opportunity to directly observe the Moon’s orbital motion.

Because the Earth is spinning, the Moon always appears to move across the sky from east to west (in the southern hemisphere, this effectively means it is moving right to left). The time it takes to move across the sky varies with the time of year, but it takes roughly 25 hours to do a full circuit.

Because of the Earth’s spinning, generally the only way we can usually observe the Moon’s orbital motion is by looking for it at the same time every day. If you do this, then instead of watching it migrate east to west over a day, you’ll see it move slowly from west to east over a couple of weeks.

In order to watch the Moon move directly, it would be possible to watch it move relative to a stationary background object. The stars could serve this purpose while the Moon is up at night, although generally it’s bright enough that it’s very difficult to see any nearby stars. The occultation of Saturn earlier this year, which I watched from home through my telescope, gave me a chance to observe its movement against the relatively stationary planet. Like with the stars though, you simply wouldn’t be able to observe this with your naked eye.

A solar eclipse is also an opportunity to directly watch the Moon’s orbital motion, as we can compare it to the Sun, as its movement is fairly negligible for everyday purposes when compared with that of the Moon. The problem there, of course, is that you can’t look directly at it without damaging your eyes. A lunar eclipse gives you the same opportunity except, unlike a solar eclipse, you can watch it directly.

If we ignore the Earth’s spin, then both the Sun and the Earth’s shadow (which, of course, must always be directly opposite one another) each take one full year to move the whole way across the sky. Because the 365 1/4 days in a year is very close to the 360 degrees in a circle, we can say that they move roughly 1 degree every 24 hours, or half a degree every 12 hours. This sounds pretty slow, but half a degree is roughly the size of the full Moon so it isn’t entirely negligible.

It takes about an hour for the Moon to move fully into the outer part of the Earth’s shadow, so in this time it moves roughly 1/12th the diamater of the Moon. For the sake of simplicity, let’s ignore this motion as well. Below I’ve put together a (rather clumsy and very imprecise) animated gif, using the images from Greg O’Beirne’s great compilation as its frames, to show this motion of the Moon holding the position of the Earth’s shadow roughly constant:

Lunar Eclipse Oct 2014 Animation

If you want to view this for yourself, the next lunar eclipse visible from New Zealand isn’t too far away. You may have read that there won’t be another total eclipse visible from New Zealand until 2018, but on the 4th of April 2015 there will be a partial solar eclipse in the evening where you’ll be able to see this. In the meantime, have a look up at the sky occasionally and notice where the Moon is (using landmarks as a guide to remember its position will help). If you make it habitual to do this at a specific time (I do it every day when I leave for work, for example) then you’ll be able to watch the Moon’s slow movement backwards across the sky.

Written by Mark Hanna

2014/10/11 at 11:46 am

ACC and Acupuncture 2

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The ACC has responded to my Official Information Act request that I mentioned in my last post on ACC and acupuncture. Here’s what I asked for in my request:

Dear Accident Compensation Corporation,

In response to an Official Information Act request from Kevin McCready in June (https://fyi.org.nz/request/1749-continue…), Mrs Koleti Vae’au wrote that:

In 2011, ACC’s research team conducted a literature review of the efficacy of acupuncture in the management of musculoskeletal pain. It found the most convincing evidence for the effectiveness of acupuncture related to the treatment of chronic neck pain and the improvement of pain and mobility in chronic shoulder pain. In terms of other injuries, evidence of the benefits of acupuncture was either inconclusive or insufficient.

I have been unable to find this particular review by searching on the ACC website, although I have found other reports such as the “Effectiveness of acupuncture in selected mental health conditions” brief report from earlier this year.

Also, if ACC has any guidelines for carrying out these reviews, could you please provide me with a copy of or link to these guidelines.

Sincerely,

Mark Hanna

Here’s a (direct PDF download) link to the mental health review that I mentioned in my request: Effectiveness of acupuncture in selected mental health conditions – Brief report [2014]

The brief conclusion of this report is:

There is limited good quality evidence to conclusively determine acupuncture’s efficacy in treatment of mental health conditions such as Major Depressive Disorder, Dysthymia, Anxiety Disorder, Borderline Personality Disorder and Post Traumatic Stress Disorder.

As I mentioned in my last post on this topic, ACC released their review of the evidence for acupuncture in the management of musculoskeletal pain in response to another OIA request. That review can be read in full here: The efficacy of acupuncture in the management of musculoskeletal pain

Here’s what ACC said in response to my OIA request yesterday:

There are only two ACC literature reviews on the efficacy of acupuncture. These are:

The efficacy of acupuncture in the management of musculoskeletal pain.

I understand from your email of 25 August 2014 that you have accessed a copy of this report and therefore do not require another copy.

Effectiveness of acupuncture in selected mental health conditions — Brief report 2014.

As you have identified, this is available on the ACC website.

In regard to ACC guidelines on literature reviews, ACC follows standard practice when undertaking literature reviews, and there are no ACC specific guidelines on this practice.

After my previous post on this topic, I was contacted by Ross Mason who told me about a similar OIA request he had made some years ago. One interesting thing I read in their response to him, which was written by the same person as their response to me, was this (bolded emphasis mine):

2. Evidence of the efficacy of the use of CAM treatments/programmes;

Schedule 1 Part 1 sections 1 & 2 of the [Accident Compensation] Act detail ACC’s liability to pay for the cost of treatment. These provisions in part include the requirement that the treatment is necessary and appropriate and of the quality required for the purpose. ACC has always required that new treatments for which payment is requested are supported by evidence of effectiveness. However it must be noted that there are many treatments that treatment providers utilise that do now have a well established evidence base.

Examples of the research that ACC does in considering new treatments can be found on the “For Providers” section of the ACC website – http://www.acc.co.nz/about-acc/research-sponsorship-and-projects/research-and-development/evidence-based-healthcare-reports/index.htm

If requested to fund CAM, ACC would require that evidence be provided for the treatments [sic] efficacy. ACC evaluation process of the evidence is detailed on the ACC website in the “For Providers, Clinical Best Practice” section – http://www.acc.co.nz/for-providers/clinical-best-practice/index.htm.

The first link, to the “Evidence based healthcare reports” page, seems to provide a little more detail on what was described as “standard practice” in response to my request:

Evidence based reviews

These reports assess the effectiveness and safety of health interventions. They are developed according to a robust methodology similar to that used by the Centre for Evidence Based Medicine (external link) and the Scottish Intercollegiate Guidelines Network (external link). This includes systematic searches of the literature, critical appraisal of existing research evidence and peer review by clinical experts.


ACC has funded acupuncture treatments for over a decade, spending over $24 million on it last year alone.

In August 2011, ACC reviewed the evidence regarding the efficacy of acupuncture for musculoskeletal pain and found that (emphasis mine):

The evidence for the effectiveness of acupuncture is most convincing for the treatment of chronic neck and shoulder pain. In terms of other injuries, the evidence is either inconclusive or insufficient.

In March 2014, ACC published a brief report on the effectiveness of acupuncture in selected mental health conditions didn’t find enough good quality evidence to provide any recommendation.

No other review of the evidence for acupuncture has been undertaken by ACC. Despite this, over the last year ACC spent significant amounts of public money on acupuncture treatments for other medical issues such as burns ($30,002), lacerations and puncture wounds ($309,458), and fractures and dislocations ($591,613).

In the past year, they spent $22,592,552 on acupuncture for soft tissue injuries. Unfortunately, their recent response to another OIA request shows that they haven’t been keeping track of which body parts were treated, so we’ve been unable to determine how much of this substantial amount of money was spent on treatments that ACC’s own findings say are not supported by evidence.

As far as I’ve been able to tell, ACC’s funding scheme for acupuncture simply isn’t consistent with the evidential requirements they claim to require, and is instead largely based on the pre-scientific notions (to quote the author of their 2011 review) detailed in their Acupuncture Treatment Profiles document. When these issues were raised with the previous ACC minister Nick Smith in 2009 he promised a review of their effectiveness would be undertaken, but in the 5 years since then no such review has taken place. This latest response of theirs has only made me feel even more strongly about my recommendations for change:

I think ACC needs to review its funding scheme for acupuncture. I think their approach to this should start with reviewing their Acupuncture Treatment Profiles document, ensuring that the only treatments contained within it are those supported by rigorous evidence, and purging pseudoscientific claims from it. If they find they need to undertake further reviews of the evidence for the use of acupuncture for particular indications, then they should do that before approving funding for it.

I think ACC should then only agree to pay for acupuncture treatments that are aligned with their Treatment Profiles document, which they should commit to reviewing at regular intervals to keep it in line with the latest evidence (I’m not sure what time interval would be most appropriate, and I understand that there is a cost involved in that work).

I’m not sure, but it’s possible some changes to legislature may be required before this becomes a reality, but if that’s the case those changes should happen. A government body should not be bound by law to fund healthcare that is not supported by evidence.

There’s one last thing I’d also like to see, although I really feel like this is a long shot. I think ACC should take an active role in discouraging healthcare practice based on the “pre-scientific notions” described in their 2011 review. I think they should do this by distancing themselves from those acupuncturists who promote it and who base their practice on it, by refusing to grant them status as registered ACC practitioners if they are found to rely on it.

Written by Mark Hanna

2014/09/04 at 5:11 pm

Green Party Health Policy

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There was a thread recently in one of the Facebook groups I’m a member of in which, among other election-related things, the Green Party’s Health Policy was being discussed. It was mentioned that the Green Party had been essentially pro-CAM, at least in the past. As I’d been considering voting for the Greens, this was something I thought I should look into further.

Here’s a link to their Health Policy. My first impressions of this document were quite positive, especially seeing that one of their “Key Principles” seems to echo the mission statement of the Society for Science Based Healthcare where it states that:

Decisions about health services should be based on the strongest possible evidence.

However, I found myself worried that this might just be paying lip service to evidence-based policy. Particularly considering the comments I’d seen regarding past policy, and some other sections of the current Health Policy such as:

The Green Party will… Find ways to integrate complementary therapies that have a sound evidence base into health services.

The Green Party will … Increase resources for physical and mental rehabilitation in… complementary practices.

Of course, complementary therapies that have a sound evidence base should be “integrated” into real medicine. That’s exactly what medicine should be – therapies with a sound evidence base. However, as I said before, I felt worried this mention of evidence may just be lip service, or perhaps that the standard of evidence required might be low (as I’ve typically seen when it comes to the promotion of complementary therapies).

As you’ll have seen if you’ve clicked on the Health Policy link, Kevin Hague is listed as the spokesperson for this policy, as well as the person to contact. So that’s what I did. Below is the email I sent him, and the response I received (much faster than anticipated – within 2 hours):

Hello Mr Hague,

My name is Mark Hanna. I don’t think we’ve met, although we were both at the New Zealand Skeptics conference in Wellington last year. I’m currently considering giving my party vote to the Greens this election but I wanted to email you first to clarify something about one of the policy statements.

I spend a lot of my spare time working with regulatory systems to combat misinformation about health and healthcare in the public sphere. The vast majority of this misinformation comes from sources that promote “complementary therapies”.

To this end, I’ve made dozens of successful complaints to the Advertising Standards Authority and Medsafe, and have recently co-founded the Society for Science Based Healthcare as part of this continued effort. I’ve also written on some aspects of publicly funded healthcare in New Zealand that I find troubling and would very much like to see change, such as ACC’s stance on acupuncture (http://sciblogs.co.nz/honestuniverse/?p=41).

I’ve read the Green Party’s Health Policy (https://home.greens.org.nz/policy/health-policy); I’m glad to see an emphasis on evidence and I strongly support with [sic] party’s focus on equality in healthcare and making it as accessible as possible. However, I’m also wary that I don’t want my party vote to inadvertently support the kind of thing I spend so much of my time fighting against. Most particularly, I am worried about point 7 under the “Whole-of-System Healthcare” section:

“Find ways to integrate complementary therapies that have a sound evidence base into health services.”

As you may be aware, the majority of complementary therapies have a very poor evidence base. Even in cases where there is a large amount of research, in general it is of poor quality, and in very many cases the use of complementary therapies is simply not supported by sound evidence.

Other sections of the Health Policy add to my concern here, such as the 1st point under “9. Post-Acute Care” which says “The Green Party will… Increase resources for physical and mental rehabilitation in… complementary practices”. Before I commit my party vote, I’d appreciate it if you could assuage my fear that the reference to sound evidence may be no more than lip service.

In general terms, what would the Green Party consider the minimum standard of a sound evidence base in this context? Could you describe what the evidence for a treatment that does not meet this standard might look like?

As part of their commitment, will the Green Party also make an effort to prevent the integration of therapies (whether “complementary” or otherwise) into health services where there is not a sound evidence base?

I also note the party has pledged to:

“Support rongoa Māori (traditional Māori healing) practitioners and practices, and develop better linkages with other health services.”

I’m wary that when dealing traditional healing practices such as rongoa Māori and Traditional Chinese Medicine, the complex issues of science- and evidence-based healthcare and cultural sensitivity and inclusiveness can become entangled. Will the Green Party maintain their commitment to basing decisions about health services being based on the strongest possible evidence even when dealing with complex and often difficult issues such as these?

I’m under the impression that other people I know who are also considering giving their party vote to the Greens could also be swayed one way or the other depending on your response. I’d appreciate it if I could have your permission to publicly share any response you send me regarding this.

Sincerely
Mark Hanna

This is the response I received from Kevin Hague:

hi Mark,
I’m an admirer of your work. Thank you for it!

As you probably know, Green Party policy is developed by members, rather than MPs, and the Policy Committee strives for consensus if possible.

if you have compared the current Health policy with its predecessor (and my statements with those of my predecessor in the role) you will have noted substantial change that I think you would be pleased with.

The statement in the principles concerning complementary therapies, is a neat compromise I think (nobody can really argue for the use of public money on something that doesn’t work, but if it does work then it should be integrated), but does give rise to your question of what kind of evidence would be sufficient. In practice it would be me as spokesperson who would interpret the meaning of the policy (this is established practice in the Green Party). My first port of call would be Cochrane. If there is no guidance there, then it’s probably a no, but as someone who used to teach at postgrad level in research methods I would also be in a position to look at any papers that are proposed as providing evidence and make an assessment.

The obverse of this commitment does also apply ie if the state is currently funding therapies with poor or no evidence of effectiveness then it should stop doing so. This applies both to ‘complementary therapies, but also to mainstream treatments (my favourite instructive example being mammary arterial ligation as a treatment for coronary heart disease – it’s worse than ineffective).

In the case of rongoa I think matters actually are more complex. In addition to the cultural sensitivity matters to which you refer there are also Article II Treaty rights, so it’s not simply a matter of evidence. And when it comes to the evidence, far fewer studies have been undertaken. You probably know that there is significant evidence internationally that such indigenous treatment systems may be effective, even though their intervention logic and mechanism are quite different from traditional western approaches (eg Kleinmann in relation to mental illness in Taiwan). It could be that strongly held cultural beliefs may create a substantial placebo effect. Sometimes, even if we know the effect is just placebo, it could be worth having. So on this point I would interpret our policy as supporting the availability of rongoa, even though the evidence base for effectiveness may not be strong. I would also support further research to create a sound evidence base, where this doesn’t currently exist.

Hope that’s useful. Please feel free to share this if you want.

Best,

Kevin

Honestly, I’m quite happy to hear this answer. It sounds to me like the mentions of evidence are more than lip service, and hopefully indicative of a change in direction for the Greens in this area. The fact that Kevin Hague is their spokesperson on Health and ACC gives me hope as well. Especially comparing him to their past Health spokesperson Sue Kedgley, who has some ideas about healthcare that are rather wacky.

I would like to make one more comment regarding the issue of traditional medicine such as rongoa. First off, rongoa is not something I’ve looked into in much depth, I don’t know much about the state of the evidence and don’t mean to discuss it here. I would like to say though, that when I referred to issues like it being “complex and often difficult”, I meant to imply that it is not as simple as it may be in some other cases, where the only important question may be “what does the evidence say?”.

These traditions are often more than just for healing, they’re part of a wider culture and the people that use them are often already part of a disadvantaged group. If we care about what’s best for people, then we also need to care about the repercussions of discouraging or somehow diminishing such a part of their culture. As Kevin mentioned in his response, this is where things like the Treaty of Waitangi become important. There’s also an important distinction to be drawn between treatments for which there is negative evidence and those for which there is no evidence one way or the other.

I certainly wouldn’t claim to have all the answers when it comes to issues like this, and I think it’s a matter on which I would do better to listen than to speak. I do agree with Kevin that it’s not simply a matter of evidence, though, and I’d welcome a discussion on this particular issue if anyone else has anything to add.

Written by Mark Hanna

2014/09/03 at 9:53 am

The Price of Painkillers Part 2: Only Misleading in Australia

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Yesterday, I wrote about how various painkillers with the same active ingredients often cost different amounts. In particular I talked about Reckitt Benckiser’s “Nurofen” ibuprofen products, some of which are advertised as targeting specific types of pain even though it doesn’t seem plausible, given that they are essentially exactly the same, that they could target different types or sources of pain.

There are a few aspects of their advertising that I think gives this impression. For one, they have products that seem intended for specific types of pain that have names like “Nurofen Migraine Pain” and “Nurofen Back Pain”. For another example, if you look on their website you’ll see that the claim “Targeted relief from pain” is pretty prominently displayed alongside their logo in the upper left hand corner:

Nurofen

The packaging of their products repeats this claim, also pretty prominently:

ibuprofen lysine 342 mg (equiv. ibuprofen 200 mg)

In 2011 Professor Paul Rolan*, head of the medical school at the University of Adelaide, laid a complaint with the Therapeutic Goods Administration (TGA) regarding a TV advertisement for Nurofen as a treatment for headaches regarding this claim. The TGA is roughly Australia’s equivalent of New Zealand’s Medsafe, as they are responsible for the regulation of therapeutic goods.

For some reason (I’m assuming it’s a bug, and have emailed them about it), although the decision is still listed on the TGA’s Complaints Resolution Panel’s website, its full details aren’t currently available. However, they have been archived in full elsewhere. The thrust of the complaint was that:

The complainant accepted that the advertised product “is undoubtedly effective” as a treatment for headache, but argued that “it works by being absorbed in the blood stream and being distributed widely around the body, not only to where it is needed but to everywhere else as well”, and that “there is no ‘targeting’ to the head and hence the phrases ‘targeted pain relief’ on the packet and the claim made in the advertisement ‘goes straight to the source of the pain’ are factually incorrect and misleading”.

The relevant section of the Therapeutic Goods Advertising Code was section 4(2)(c), which states that:

An advertisement for therapeutic goods must not… mislead, or be likely to mislead, directly or by implication or through emphasis, comparisons, contrasts or omissions

Reckitt Benckiser’s response was basically that they weren’t being misleading because anyone seeing their advertisements would realise that when they say Nurofen “goes straight to the source of pain”…

an ordinary and reasonable person viewing the advertisement would interpret it as conveying “that Nurofen goes to and acts at the source of the pain associated with a headache, namely where the headache is located in the head” and not “that Nurofen will only go to and act at the source of the pain.”

I don’t find myself convinced by this rebuttal. It seems analogous (if you’ll pardon the violent example) to saying a bomb targets a single person, but that’s not misleading just because it also happens to destroy everyone nearby as well.

You can read the full findings of the panel yourself at the link above, but for a synopsis they essentially agreed with Professor Rolan in that:

26. The Panel did not accept that, in being dispersed throughout the body, the advertised product could reasonably be said to “target” or “go straight to the source of” headache pain or the site of a headache.

They also found Reckitt Benckiser’s rebuttal unconvincing:

28. The Panel noted that the advertiser had argued that consumers were generally well aware that Nurofen was suitable for many types of pain. On this basis, the advertiser argued that consumers would not interpret the advertisement as conveying a “targeted” action in the sense alleged by the complainant.

29. The Panel did not accept this argument. While the Panel accepted that consumers might generally be aware that Nurofen is suitable for many types of pain, this does not mean that a reasonable consumer would be aware that Nurofen is normally distributed throughout the body when taken. The Panel was satisfied that a reasonable consumer, noting the references to “targeted relief of pain” and “going… to the source of pain”, would conclude that the active components of the product travelled specifically to areas of the body affected by pain – in this instance, the part of the head affected by a headache. The reasonable consumer would also conclude that the active components of the product would not travel elsewhere throughout the body to any significant degree. The Panel noted that although the advertisement did not state exactly how Nurofen might physically concentrate in areas of the body affected by pain and target them, it did convey that Nurofen would do so. That Nurofen might also be understood to be beneficial for other types of pain did not alter this, because in such cases Nurofen would again be understood to concentrate at the site of pain.

As a result, Reckitt Benckiser was told to stop that particular advertisement and to not make the same representations in other advertisements. Of course, this only applies in Australia; to my knowledge Reckitt Benckiser hasn’t changed their advertising strategy here in New Zealand. As far as I know, it also hasn’t been challenged here.

I’m reminded of another case of what I consider to be misleading advertising from a pharmaceutical company that I’ve written about previously. When GlaxoSmithKline has advertised their “Panadol Extra” product, they have claimed it is “37% more powerful than standard paracetamol tablets”. The catch is that, when they say “more powerful”, they’re referring to potency, not efficacy, so instead of meaning the pills give 37% more powerful pain relief it means you can take 37% less Panadol Extra to get the same amount of pain relief. This might be difficult, however, considering that a single Panadol Extra pill contains exactly the same amount of paracetamol as a standard paracetamol tablet – 500 mg.


* Professor Rolan is also a member of Friends of Science in Medicine, a great Australian organisation dedicated to promoting science and fighting pseudoscience in the medical field. They do some great work across the ditch; I’m a member and I think they deserve your support as well.

The Price of Painkillers

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DISCLAIMER: Since I mention some specific branded pharmaceutical products in this article, I want to make it very clear that I don’t intend to promote any particular product and have no conflict of interests to declare.


Last Saturday, the New Zealand Herald’s Consumer Affairs reporter Morgan Tait published a very good article about a topic I’ve come across before. Many painkiller products cost different amounts despite having exactly the same active ingredients, and for some reason this isn’t common knowledge. Here’s a link to her article: Expensive and cheap pain-relief pills use same ingredients

I first discovered this from watching a Consumer Advocacy TV show from Australia called The Checkout. It’s quite light-hearted in its approach to issues, which I admit I find a bit painful at times, but that’s just a matter of taste and the information in the show is pretty consistently good. Although its content is sometimes only relevant to an Australian audience, a lot of it is also relevant to New Zealanders and I’d highly recommend you watch it if you get the chance.

Their episode that deals with painkillers is season 1 episode 5. The main point, which is also made in Ms Tait’s recent article, is that many painkillers you can find in pharmacies and supermakets cost different amounts but have exactly the same active ingredients. The prime example given in both the article and the episode is Nurofen.

Nurofen is an ibuprofen-based painkiller made by the pharmaceutical company Reckitt Benckiser. They sell a product range of “specific pain relief” products:

  • Nurofen Migraine Pain
  • Nurofen Tension Headache
  • Nurofen Back Pain
  • Nurofen Period Pain

(Before I go into any criticism of these products, I do want to note that the efficacy of these products is not something I mean to call into question. I only intend to examine issues associated with their advertising and sale.)

If you look at the Nurofen website, you’ll also see that they have a lot of marketing claiming that their products can target specific types or sources of pain. For example, here’s the Nurofen logo as it appears in the upper left corner of their New Zealand website:

Nurofen

As you can see, their slogan “Targeted relief from pain” is pretty prominently displayed. Other sections of the site, such as their “Nurofen Treatment Advisor” (which recommends Nurofen products based on what sort of pain you say you have) also imply that certain products are more applicable to certain types of pain than others. However, all of the products I listed above have exactly the same active ingredient: 342 mg ibuprofen lysine.

I hope I don’t need to explain that, as all products are taken in the same way (a “caplet”) and contain the same active ingredient, your body isn’t able to distinguish between them so they’re all going to act in exactly the same way. If you take a Nurofen “Nurofen Period Pain” caplet for your migraine pain, it will be just as effective as a “Nurofen Migraine Pain” caplet.

The obvious explanation for this is that having specific products makes it easier for consumers to understand that this product can help with their specific type of pain. It probably helps Reckitt Benckiser sell more products too, just quietly. However, I can definitely see how this could be confusing to consumers – I know I was surprised for this very reason when I found out the products were effectively identical – and if the products are available for different prices people might end up paying more than they need to for exactly the same product.

The price issue, of course, is not an issue if all the products cost the same. However, this isn’t always the case. After I first became aware of this in March this year, I had a look and found that Pharmacy Direct stocked these products for different prices:

Of course it’s not particularly surprising that the 12 caplet packs are relatively more expensive than the 24 caplet packs, but the price differences between packs of the same size seems quite odd. I also find it very strange that it’d be cheaper to by two 12 caplet packs of Nurofen Migraine Pain than a single 24 caplet pack of the same product.

I emailed Pharmacy Direct on the 27th of March to ask about the price discrepancies. Their response was basically that yes, the products do all have exactly the same ingredient, and they thought the suppliers did that for marketing reasons. They told me that the difference in price was due to them selling more of some packs than others, so they can justify buying more of them from their supplier and getting a bulk discount that allows them to sell the products to consumers for a lower price. They also offered me the option to pay the lowest price for any of the products if I mentioned our conversation in the “notes” section when buying them online.

If you’re looking for a cheaper ibuprofen-based painkiller as an alternative to Nurofen, you can buy a 24 pack of Countdown’s “Homebrand” version (just one example, I’m sure there are others) for $2.99. That’s $0.12 per pill, compared with $0.73 per pill as the cheapest Nurofen branded option from Pharmacy Direct. Now if you check the packet you’ll see that Nurofen pills contain 342 mg of ibuprofen lysine, whereas this particular unbranded option contains 200 mg of ibuprofen per pill.

I’m by no means an expert on the differences between ibuprofen and ibuprofen lysine, but I’m under the impression that 342 mg ibuprofen lysine will have a faster onset than 200 mg ibuprofen but provide the same amount of pain relief. If anyone knows more please say so in the comments. If you look at a pack of Nurofen, you’ll see that they’re considered equivalent:

ibuprofen lysine 342 mg (equiv. ibuprofen 200 mg)

ibuprofen lysine 342 mg (equiv. ibuprofen 200 mg)

Other types of painkiller can suffer from similar problems. For example, a 20 pack of Panadol (500 mg paracetamol) from Countdown costs $4.19, but a 20 pack of their own equivalent “Home Brand” paracetamol (which also contains 500 mg paracetamol per pill) costs $2.19.

While these cheaper alternatives do often contain the same amount of the same active ingredient (or equivalent), they’d unlikely to be exactly the same. For example, they may use different “fillers” to make up the rest of the pill. If you’re concerned about the differences or want to know more, your GP or pharmacist should be able to give you some advice.

It can be worth looking for an unbranded version if you’re looking to save. So-called “generics” are typically made available after the patent on a drug ends, and other companies are able to start producing and selling it. They tend to be much less expensive, and are sometimes subsidised if you have a prescription, but are often also less well-known.

Written by Mark Hanna

2014/08/28 at 1:45 pm

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