As discussed regularly on this blog, there is plenty of evidence to show that many chiropractors, homeopaths, and naturopaths discourage their patients from getting vaccinated. Now, a further investigation from the US seems to confirm these findings.
The data from the 2017 National Health Interview Survey (NHIS; n = 26,742; response rate 80.7%) was used for this purpose. Prevalences of flu vaccination, consultations with SCAM practitioners in the past 12 months, and their potential interactions were examined.
A total of 42.7% of participants had received the flu vaccination in the past 12 months, 32.4% had seen one or more SCAM practitioners. Users of any type of SCAM were as likely as non-users to have received a flu vaccination (44.8% users versus 41.7% non-users; p = 0,862; adjusted odds ratio [AOR] = 1.01, 95% confidence interval [CI] = 0.95-1.07).
Regarding specific SCAMs, individuals consulting with
- naturopaths (p < 0.001; AOR = 0.67, 95 %CI = 0.54-0.82),
- homeopaths (p < 0.001; AOR = 0.55; 95 %CI = 0.44-0.69),
- chiropractors (p = 0.016; AOR = 0.9, 95 %CI = 0.83-0.98)
were less likely, while other SCAM approaches showed no significant association with flu vaccination behavior. Independent predictors for a flu shot were prior diabetes, cancer, current asthma, kidney disease, overweight and current pregnancy. As well, higher educational level, age, ethnicity, health insurance coverage, and having seen a general physician or medical specialist in the past 12 months were also associated with a higher vaccination rate.
The authors concluded that SCAM users were equally likely to receive an influenza vaccination compared with non-users. Different complementary therapies showed varied associations with vaccination behavior. Further analyses may be needed to distinguish influencing factors among patients’ vaccination behavior.
This investigation confirms the prevalent anti-vax stance within chiropractic, homeopathy, and naturopathy. The effect is strongest by far with homeopaths. Nothing new! We knew this for a very long time. The question is WHAT ARE WE DOING ABOUT IT? Or more specifically, are the professional organizations of these SCAM professions finally going to take any actions against even the most rabid anti-vaxxers in their midst?
And the answer?
You guessed it: NO!
And the irony of all this must not get lost here: chiropractors, homeopaths, naturopaths, and their respective organizations all pride themselves regularly that they attribute particular importance to disease prevention.
Recently, I wrote about the court case of a French naturopath. Last week, the judge has issued his verdict. Miguel Barthéléry was sentenced to a two-year suspended prison term and to a fine of 5 000 Euros. Two cancer patients had died following his treatments and recommendations. Barthéléry was also found guilty of impersonating a doctor and illegally practising medicine. In addition, he was also banned for life from practising as a healthcare professional.
The Paris criminal court found that Miguel Barthéléry had deliberately created confusion about his qualifications by presenting himself as a doctor on the internet and in text messages to the two victims. The defendant had claimed to have a doctorate and a post-doctorate from the United States. The judgment “has the consequence of dissuading all those who engage in the same abuses, they are now warned that we can not do anything with the health of people,” said the judge.
The case had begun in February 2019 with the complaint of the companion of a man who had died two months earlier of testicular cancer. Diagnosed in 2016, the patient had not consulted a doctor but had preferred to follow a “health plan” drawn up by the naturopath. It was based on fasting and cures, raw food, and essential oils. Later, the family of a Belgian physiotherapist, who died of uterine cancer at the age of 39, joined the legal case. However, according to Code Source, the Parisien podcast, the case is more extensive, with seven further suspicious deaths of Barthéléry’s patients.
Barthéléry’s lawyer said that the decision “raises questions more generally about the appreciation that we now have of alternative therapeutic practices, which now seem, although not prohibited by law, to be subject to condemnation by the courts.”
The bad news for German homeopathy just keeps on coming. As I reported, recent events must be depressing for homeopaths, e.g.:
- A recent investigation disclosed that the German homeopathy cult is at the heart of Germany’s anti-vax movement.
- In July 2021, a German court ruled against a homeopathic HCG remedy.
- In 2020, a German study failed to show that homeopathy is cost-effective.
- In 2019, the attempt by a German homeopathy manufacturer to silence critics backfired spectacularly.
- About 10 years ago, 5 German firms clubbed together supporting a journalist at the tune of Euro 30 000/year to defame me (at the time I was one of the few who regularly informed the public about the evidence on homeopathy). The plot was discovered and published whereupon the journalist committed suicide.
After heated debates in the run-up, the Bavarian Medical Association decided yesterday to ditch the postgraduate education program in homeopathy for its doctors. This means that, of the 17 regional medical associations in Germany, 12 have now discontinued their further education efforts in homeopathy. The ones that have not yet done so are:
In the past months, homeopaths had collected 11,597 signatures in favor of maintaining the additional qualification of homeopathy. The ~ 400 doctors in Bavaria, who have acquired ‘homeopathy’ as an additional title, will be permitted to continue to use it.
The spokesperson of the Information Network Homeopathy, Dr. Christian Lübbers, welcomed the decision of the Medical Association. It was a “landslide victory for patient safety”, he said. The Bavarian regional chairman of the German Central Association of Homeopathic Doctors, Dr. Ulf Riker, regretted the outcome of the vote and added: “We will consider legal steps very seriously.” I would advise against such a step which would only render homeopaths more ridiculous than they already are.
Yes, it’s bad news for German homeopaths – very bad news indeed. Of course, homeopathy fans will claim that it is all a sinister conspiracy against them. Sadly, they are unable to realize that the only driving force behind the long-overdue decline of German homeopathy is the evidence: HOMEOPATHY DOES NOT WORK BEYOND PLACEBO and therefore it has no place in the evidence-based medicine of the 21st century.
One argument that we hear regularly in the comment sections of this blog and elsewhere goes something like this:
“Why worry about a bit of so-called alternative medicine (SCAM like homeopathy or chiropractic, or Reiki, or Bach flower remedies, or detox, etc.)? Why should it bother us? Why not let everyone use what they want? Why not be a bit more tolerant?”
Tolerance is defined as sympathy or indulgence for beliefs or practices differing from or conflicting with one’s own. It is, of course, a quality that normally should be welcomed, taught, and celebrated. So, why not be more tolerant with enthusiasts of pseudoscientific SCAM?
In my view, there are several reasons.
- Ineffective therapies harm patients. The public tends to believe that SCAM is inherently safe. This is, of course, not true – think of chiropractic, for instance. But some treatments seem entirely harmless. Homeopathy might be a good example; its remedies contain nothing and therefore homeopathy can do no harm. Sadly, this is not true either. If a patient uses homeopathy to treat a serious condition, she is likely to harm herself by not treating that condition effectively. In extreme cases, this course of action can be fatal.
- Ineffective therapies are a waste of resources. It seems obvious that the money spent on something that does not work is money wasted. This is true whether we buy a car that is beyond repair or a SCAM that does not work beyond placebo.
- Pseudoscience makes a mockery of evidence-based medicine. If we are tolerant towards useless SCAM and accept that some people make money on, and mislead the public about SCAM, we basically send out a message that evidence is of secondary importance. This would weaken the trust in evidence-based medicine which, in turn, is bound to render healthcare less effective and stand in the way of progress.
- Pseudoscience undermines rationality and one form of irrationality begets another. Perhaps the biggest danger of tolerating promoters of quackery is that this undermines rational thinking far beyond the realm of healthcare. “Those who can make you believe absurdities can make you commit atrocities,” wrote Voltaire. I fear that he might have been correct.
In my view, tolerance about pseudoscientific, implausible, ineffective, or harmful SCAMs is misplaced. On the contrary, I feel that it is our duty to limit the harm they do to the public, patients, and progress by exposing them for what they are.
Germany seems to have a significant problem with anti-vaxxers. Today, only 68% of the population has had a COVID vaccination. In the UK and France, these figures are 72% and 75% respectively.
This study investigated the willingness to vaccinate of parents of minors and people without children who are minors. The investigation was based on a random sample of Germans (telephone survey, n = 2,014, collected between 12 November and 10 December 2020). The evaluation is primarily based on the sub-sample of people with minors in the household (n = 461).
Parents of minors consistently show a lower willingness to be vaccinated with a COVID-19 vaccine than respondents without minors (54.1% vs 71.1%). Fathers show a stronger willingness to be vaccinated than mothers. Furthermore, men are more willing to get their own child vaccinated with a COVID-19 vaccine than are women.
The authors concluded that among parents and especially mothers, a considerable misrepresentation of vaccination risks and frequent beliefs in vaccination conspiracy theories can be observed. Clear and easily understandable information on the effects and side effects of vaccination with a COVID-19 vaccine by relevant institutions and physicians is recommended.
And what has this to do with so-called alternative medicine (SCAM) and homeopathy?
In the results section of the paper, the authors report interesting additional findings (my translation):
In the total sample, a significantly higher willingness to vaccinate is associated with the rejection of “alternative healing methods”. There is also a significant correlation between the attitude towards homeopathy and one’s own willingness to vaccinate: if homeopathy is supported, the willingness to vaccinate is lower. This correlation between the attitude towards homeopathy and willingness to vaccinate is also evident in the sub-sample of parents. Among parents, it is again women who significantly more often have a positive attitude towards homeopathy than men, who more often do not think anything of it.
The authors also report that the parents were asked: “If a vaccine against the coronavirus is approved in Germany, would you get vaccinated?” CERTAINLY NOT was the answer of:
- 41% of homeopathy fans
- 10% of people who thought nothing at all about homeopathy
- 15% of participants who were not fully convinced by homeopathy
Yes, Germany seems to have a problem with the anti-vaccination brigade but it seems that at the heart of it is a problem with a homeopathy cult.
This article from AP News caught my attention. Here it is (I haven’t changed a word):
The flashy postcard, covered with images of syringes, beckoned people to attend Vax-Con ’21 to learn “the uncensored truth” about COVID-19 vaccines.
Participants traveled from around the country to a Wisconsin Dells resort for a sold-out convention that was, in fact, a sea of misinformation and conspiracy theories about vaccines and the pandemic. The featured speaker was the anti-vaccine activist who appeared in the 2020 movie “Plandemic,” which pushed false COVID-19 stories into the mainstream. One session after another discussed bogus claims about the health dangers of mask wearing and vaccines.
The convention was organized by members of a profession that has become a major purveyor of vaccine misinformation during the pandemic: chiropractors.
At a time when the surgeon general says misinformation has become an urgent threat to public health, an investigation by The Associated Press found a vocal and influential group of chiropractors has been capitalizing on the pandemic by sowing fear and mistrust of vaccines.
They have touted their supplements as alternatives to vaccines, written doctor’s notes to allow patients to get out of mask and immunization mandates, donated large sums of money to anti-vaccine organizations and sold anti-vaccine ads on Facebook and Instagram, the AP discovered. One chiropractor gave thousands of dollars to a Super PAC that hosted an anti-vaccine, pro-Donald Trump rally near the U.S. Capitol on Jan. 6.
They have also been the leading force behind anti-vaccine events like the one in Wisconsin, where hundreds of chiropractors from across the U.S. shelled out $299 or more to attend. The AP found chiropractors were allowed to earn continuing education credits to maintain their licenses in at least 10 states.
On this blog, I have often discussed that chiropractors tend to be anti-vax. It all goes back to their founding father, DD Palmer, who famously wrote:
- Vaccination and inoculation are pathological; chiropractic is physiological,
- and who in 1894, published his views on smallpox vaccination: ‘…the monstrous delusion … fastened on us by the medical profession, enforced by the state boards, and supported by the mass of unthinking people …’
- and who stated in 1896 that keeping tissue healthy is therefore the best prevention against infections; and this is best achieved by magnetic healing.
But that’s long ago! We are not like that anymore! … say the chiros of today.
Do you believe them?
If so, you might want to read this article by Jann Bellamy. Or alternatively, just look at some of my finds from the Internet:
So-called alternative medicine (SCAM) use has been increasingly prevalent among Americans, whereas its relationship with medical non-adherence is unknown. Using the National Health Interview Survey, this analysis evaluated the use of SCAM modalities and their association with cost-related nonadherence to medical care (CRN) among older Americans by gender strata.
Americans, aged 50 or above in the 2012 National Health Interview Survey, were included to evaluate the use of SCAM modalities and their association with CRN. SCAM modalities were categorized as the use of the following in the past 12 months:
- 1) herbal supplements;
- 2) chiropractic or osteopathic manipulations;
- 3) massage;
- 4) Yoga, tai chi, or qigong;
- 5) Mantra/mindfulness/spiritual meditation,
- 6) acupuncture;
- 7) mind-body therapy;
- 8) other SCAM modalities including homeopathy, naturopathy, traditional healers, energy healing therapy, biofeedback, hypnosis, and craniosacral therapy.
CRN was defined as needing medical care but not receiving it due to costs and/or having medical care delayed due to costs in the past 12 months. The investigators developed a multivariable logit model to assess the association of the use of SCAM modalities and CRN controlling for patients age, gender, race, ethnicity, insurance status (Medicare, Medicaid, VA/Tri-care, no-insurance, or private insurance), and comorbid conditions (diabetes, arthritis, back and neck problems, heart condition, stroke, lung and breathing problems, and cancer).
A total of 16,360 older Americans were included in the analysis, with 11,278 (68.9%) reporting at least one SCAM modality use, and 1,992 (12.2%) of them reported CRN. Among the 8 SCAM modalities, compared to those not using SCAM, those who used chiropractic were 94% more likely (p=0.01), those who used Mantra/mindfulness/spiritual meditation were 106% more likely (p<0.01), and those using other modalities were 42% more likely (p=0.07) to report CRN. In contrast, those who used mind-body therapy were 43% less likely (p=0.04) to report CRN. The other 4 modalities did not achieve statistically significant levels although the odds ratios were mostly greater than 1.
The authors argue that the differential association between the SCAM modality use and CRN suggested a complex relationship between the utilization of SCAM and patients’ non-adherence to medical care. It is possible that the out-of-pocket payments for those services significantly increased patients’ cost burden and thus made the use of other medical care unaffordable, and it’s also possible that those who already had low resources were more likely to seek SCAM to substitute for more expensive conventional care. Either of these scenarios would present a serious challenge.
The authors concluded that both men and women are more likely to report financial distress while using various SCAM modalities.
These findings are not easy to interpret. To me, they suggest that, in the US, many consumers have been persuaded to prioritize SCAM over conventional medicine, even if they can ill afford it. It throws a dim light on the US society where some folks seem to struggle to pay for what is essential while continuing to afford the superfluous.
In my view, in a just and non-decadent society, conventional healthcare must be free for everyone at the point of delivery, and SCAM is at best an extra that those who want it should pay out of their own pocket.
Prior research has generated inconsistent results regarding vaccination rates among patients using so-called alternative medicine (SCAM). Given that SCAM includes a wide range of therapies – about 400 different treatments have been counted – variable vaccination patterns may occur within consultations with different types of SCAM practitioners.
A recent analysis aimed to evaluate differences between categories of SCAM regarding vaccination behavior among US adults.
were less likely to be vaccinated. Other SCAMs showed no significant association with flu vaccination behavior. Independent predictors for a flu shot were prior diabetes, cancer, current asthma, kidney disease, overweight and current pregnancy. As well, higher educational level, age, ethnicity, health insurance coverage, and having seen a general physician or medical specialist in the past 12 months were also associated with a higher vaccination rate.
The authors concluded that SCAM users were equally likely to receive an influenza vaccination compared with non-users. Different SCAM therapies showed varied associations with vaccination behavior. Further analyses may be needed to distinguish influencing factors among patients’ vaccination behavior.
This survey confirms what we have discussed repeatedly on this blog (see, for instance here, here, here, here, and here). The reason why consumers who consult naturopaths, homeopaths, or chiropractors get vaccinated less regularly is presumably that these practitioners tend to advise against vaccinations. And why do they do that?
- Naturopaths claim that vaccines are toxic and their therapeutic options protect against infections.
- Homeopaths claim that vaccines are toxic and their therapeutic options protect against infections.
- Chiropractors claim that vaccines are toxic and their therapeutic options protect against infections.
Do these ‘therapeutic options’ – detox, nosodes, spinal manipulation – have anything in common?
Yes, they are bogus!
Many naturopaths, homeopaths, and chiropractors seem to be a risk to public health.
On 19-30 April 2021 & 1-2 September, 2021 the Professional Conduct Committee of the General Chiropractic Council considered the case of Arleen Scholten, the chiropractor who treated John Lawler, the patient who died after her treatment. Details of the case can be found in the following posts:
- Former chiropractor fined after death of MS patient receiving hyperbaric oxygen therapy
- Death by chiropractic: thoughts about the sad case of Mr Lawler
- The death of Mr Lawler highlights the scandals of chiropractic
- Death by chiropractic neck manipulation? More details on the Lawler case
The Committee considered there had been breaches of the Code, those breaches occurred as a result of Mrs. Scholten’s state of mind at the time and not as a result of a deliberate intention on her part to be inaccurate or misleading. In light of those circumstances, the Committee considered other members of the profession and fully informed members of the public would not consider her failings to be morally reprehensible or deplorable, but rather would consider them regrettable but understandable in the exceptional, albeit tragic, circumstances of this case. The Committee, therefore, agreed with the GCC’s expert witness Mr Brown and did not think Mrs Scholten’s conduct fell far short of the standard required of a registered chiropractor. The Committee was not satisfied, therefore, that her behaviour amounted to unacceptable professional conduct. Accordingly, the Committee found the allegation of UPC not to be well-founded.
How can this be right?
To remind us of the case, here is what I wrote about it previously:
The tragic case of John Lawler who died after being treated by a chiropractor has been discussed on this blog before. Naturally, it generated much discussion which, however, left many questions unanswered. Today, I am able to answer some of them.
- Mr Lawler died because of a tear and dislocation of the C4/C5 intervertebral disc caused by considerable external force.
- The pathologist’s report also shows that the deceased’s ligaments holding the vertebrae of the upper spine in place were ossified.
- This is a common abnormality in elderly patients and limits the range of movement of the neck.
- There was no adequately informed consent by Mr Lawler.
- Mr Lawler seemed to have been under the impression that the chiropractor, who used the ‘Dr’ title, was a medical doctor.
- There is no reason to assume that the treatment of Mr Lawler’s neck would be effective for his pain located in his leg.
- The chiropractor used an ‘activator’ which applies only little and well-controlled force. However, she also employed a ‘drop table’ which applies a larger and not well-controlled force.
I have the permission to publish the submissions made to the coroner by the barrister representing the family of Mr Lawler. The barrister’s evidence shows that:
The chiropractor, Mrs. Scholten, had been accused by the GCC of unacceptable professional conduct. The exact text of the GCC reads as follows :
1. Between 31 July 2017 and 11 August 2017, you provided chiropractic care and
treatment to Patient A at Chiropractic 1st, 68 The Mount, North Yorkshire, YO24 1AR,
2. On 11 August 2017 you provided treatment to Patient A which included:
a. a drop technique applied to the thoracic spine;
b. the use of an Activator applied to the thoracic spine;
c. the use of an Activator applied to the cervical spine.
3. Following the drop technique, Patient A indicated he was in discomfort and had lost sensation in his arms and you inappropriately continued treatment.
4. During the course of a subsequent 999 telephone call:
a. you told the call handler that Patient A had laid on the adjusting table and you had used the Activator on his midback;
b. you told the call handler that when you were using the Activator on Patient A’s midback he had said his hands had gone numb;
c. you told the call handler that as Patient A was elderly you had never used any manual adjustment on Patient A;
d. you omitted to tell the call handler that you had used a drop technique on Patient A;
e. you omitted to tell the call handler that Patient A had first expressed discomfort following the drop technique;
f. you omitted to tell the call handler that you had treated Patient A’s cervical spine.
5. When paramedics arrived at the Clinic:
a. you told them words to the effect that you had manipulated Patient A’s midback with the use of an Activator;
b. you told them words to the effect that Patient A had first complained of discomfort when you had been using the Activator on his midback;
c. you omitted to tell the paramedics you had used a drop technique on Patient A;
d. you omitted to tell the paramedics that Patient A had first expressed discomfort following the drop technique;
e. you omitted to tell the paramedics that you had treated Patient A’s cervical spine;
f. you demonstrated the force applied by an Activator on one of the paramedic’s arms.
6. In Patient A’s records for 11 August 2017:
a. you recorded that you had used the Activator on Patient A’s thoracic spine at T2/3 level;
b. you recorded that Patient A had directly said his arms felt numb;
c. you omitted to record that you had used a drop technique on Patient A;
d. you omitted to record that you had treated Patient A’s cervical spine.
7. Your comments and omissions as set out above at 4 and/or 5, and/or as recorded at 6 above, were;
c. dishonest in that you intended to mislead as to the precise details of the treatment you had provided Patient A
Mr Goldring, on behalf of Mrs Scholten, indicated that the following facts were admitted: Particulars 1, 2(a), 4(a), 4(b), 4(c), 4(d), 5(a), 5(b), 5(c), 5(f), 6(a), 6(b), 6(c) and 7(a) and (b), insofar as they related to the aforementioned admitted facts. The Chair therefore announced that those matters were found proved. Later in the proceedings Mr Goldring indicated that 7(a) and 7(b) were not in fact admitted in respect of 4(c) and 6(b), since it was Mrs Scholten’s case that she had not used any manual adjustment on Patient A, (Particular 4(c)) and the record that Patient A had directly said his arms felt numb was accurate, (Particular 6(b)). Accordingly, the Chair formally announced that position.
END OF QUOTES
I am totally baffled by this ruling.
- What about the fact that the chiropractor’s treatment was not even indicated?
- What about the fact that no informed consent was obtained?
- What about the fear that the chiropractor moved her patient after the injury had happened and made an attempt of ‘mouth to mouth’ resuscitation which seems to have aggravated the injury?
- What about the fact that she misled the paramedics which then caused them not to stabilise Mr. Lawlwer’s neck?
Is the GCC truly saying that, as long as a chiropractor panics, all these mistakes can be excused? I am at a complete loss trying to understand the GCC ruling and very much hope that someone can explain it to me.
Former chiropractor Malcolm Hooper, 61, and hyperbaric oxygen therapy provider Oxymed Pty Ltd have been fined following the death of a customer in 2016. They were each convicted of three work safety-related charges, all of failing to ensure a workplace is safe and without risks to health. Hooper was fined $176,750, while the company was fined $550,000. Oxymed was trading as HyperMed at its South Yarra premises in April 2016 when a long-term client with multiple sclerosis and a history of life-threatening seizures came in for treatment. He was later found unconscious in a single-person hyperbaric chamber, taken to hospital, and placed on life support, but died five days later.
The County Court heard that both the company and Hooper had an inadequate system in place for assessing the risks oxygen therapy could pose to clients, and an inadequate system too for developing plans to eliminate or reduce those risks. In her judgment, County Court judge Amanda Fox said HyperMed wasn’t a hospital nor a medical practice and had been described as an “alternative health facility”. Hooper had already been deregistered in 2013 by the national board for chiropractors for misleading and deceptive advertising about the benefits of hyperbaric treatment.
Hyperbaric oxygen therapy involves administering pure oxygen in a pressurised environment, with the heightened air pressure allowing a patients’ lungs to gather much more oxygen than would be possible under normal conditions. The therapy is not based on strong data. A systematic review failed to find good evidence for hyperbaric oxygen therapy as a treatment of multiple sclerosis:
Multiple sclerosis (MS) is a chronic, inflammatory, and degenerative neurological illness with no cure. It has been suggested that Hyperbaric Oxygen Therapy (HBO(2)T) may slow or reverse the progress of the disease. This article summarizes the clinical evidence for the use of HBO(2)T in the treatment of MS. We conducted a literature review focused on the interaction of hyperbaric oxygenation and MS. In particular, we appraised the clinical data regarding treatment and performed a meta-analysis of the randomized evidence using the methodology of the Cochrane Collaboration. We found 12 randomized studies in the area, all of which were performed between 1983 and 1987. A meta-analysis of this evidence suggests there is no clinically significant benefit from the administration of HBO(2)T. The great majority of randomized trials investigated a course of 20 treatments at pressures between 1.75ATA and 2.5ATA daily for 60-120 min over 4 weeks against a placebo regimen. None have tested the efficacy of HBO(2)T against alternative current best practice. No plausible benefit of HBO(2)T on the clinical course of MS was identified in this review. It remains possible that HBO(2)T is effective in a subgroup of individuals not clearly identified in the trials to date, but any benefit is unlikely to be of great clinical significance. There is some case for further human trials in selected subgroups and for prolonged courses of HBO(2)T at modest pressures, but the case is not strong. At this time, the routine treatment of MS with HBO(2)T is not recommended.
The case reminds me of that of John Lawler. Mr. Lawlwer’s chiropractor also used a therapy that was not indicated, broke his neck (to put it crudely), and subsequently proved herself more than inept in saving his life. It suggests to me that some chiros may not be trained adequately to deal with emergencies. If that is true, they should perhaps focus less on practice-building courses and more on first aid instructions.