MD, PhD, MAE, FMedSci, FRSB, FRCP, FRCPEd.

risk

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The origin of coronavirus 2 (SARS-CoV-2) has been the subject of intense speculation and several conspiracy theories, not least amongst the enthusiasts of so-called alternative medicine. Now Australian scientists have attempted to identify the origin of the coronavirus 2 (SARS-CoV-2). As this is undoubtedly a most sensitive subject, let me show you the unadulterated abstract of their paper:

The origin of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is contentious. Most studies have focused on a zoonotic origin, but definitive evidence such as an intermediary animal host is lacking. We used an established risk analysis tool for differentiating natural and unnatural epidemics, the modified Grunow–Finke assessment tool (mGFT) to study the origin of SARS-COV-2. The mGFT scores 11 criteria to provide a likelihood of natural or unnatural origin. Using published literature and publicly available sources of information, we applied the mGFT to the origin of SARS-CoV-2. The mGFT scored 41/60 points (68%), with high inter-rater reliability (100%), indicating a greater likelihood of an unnatural than natural origin of SARS-CoV-2. This risk assessment cannot prove the origin of SARS-CoV-2 but shows that the possibility of a laboratory origin cannot be easily dismissed.

The somewhat clumsy wording harbours explosive potential. It is more likely that the pandemic was started by a laboratory accident than by a zoonosis. In this case, it would be man-made rather than natural. The authors of the paper do, however, caution that their analysis does not prove the origin of the coronavirus. They merely speak of likelihoods. Moreover, it seems important to stress that there is no scientific evidence that Sars-CoV-2 was deliberately developed as a biological warfare agent.

Will this paper put an end to speculation and conspiracy?

I doubt it!

 

 

 

The Amercian Medical Association (AMA) recently published a lengthy article on naturopathy in the US. Here are some excerpts:

There are three types of health professionals who offer naturopathic treatment:

  • Naturopathic doctors. These nonphysicians graduate from a four-year, professional-level program at an accredited naturopathic medical school, earning either the doctor of naturopathy (ND) degree or the doctor of naturopathic medicine (NMD) degree.
  • Traditional naturopaths, who have obtained education through some combination of a mentorship program with another professional or at an alternative clinic, distance-learning program or classroom schooling on natural health, or other holistic studies.
  • Other health professionals such as chiropractors, massage therapists, dentists, nurses, nutritionists, or physicians who practice under a professional license but include some naturopathic methods in their practice and who may have studied on their own or taken courses on naturopathic methods.

At least 24 states and the District of Columbia regulate the practice of naturopathy. In order to be licensed, naturopaths in these states must earn an ND or NMD from an accredited naturopathic program and pass the Naturopathic Physicians Licensing Exam. Three states—Florida, South Carolina and Tennessee—prohibit the practice of naturopathy. In states that neither license nor prohibit the practice of naturopathy, traditional naturopaths and NDs alike may practice without being subject to state regulation.

Postgraduate training is neither common nor required of graduates of naturopathic schools, except in Utah … less than 10% of naturopaths participate in an approved residency, and such residencies last only a year and lack a high degree of standardization.

… naturopaths are required to get at least 1,200 hours of direct patient contact, physicians get 12,000–16,000 hours of clinical training…

ND programs emphasize naturopathic principes—for example, the healing power of nature—and naturopathic therapeutics such as botanical medicine, homeopoathy and hydrotherapy. Coursework in naturopathic therapeutics is combined with, and taught alongside, coursework in sciences. But there are no specifications around the number of hours required in each area … naturopathic students may lack exposure to key clinical scenarios in the course of their training … naturopathic students’ clinical experience is typically gained through outpatient health care clinics, as naturopathic medical schools typically do not have significant hospital affiliation. This means there is no guarantee that a naturopathic student completing a clinical rotation will see patients who are actually sick or hospitalized, and they may not be exposed to infants, children, adolescents or the elderly. It has been said that naturopaths tend to treat the “worried well.”

… Naturopaths claim they are trained as primary care providers and, as such, are educated and trained to diagnose, manage and treat many conditions, including bloodstream infections, heart disease and autoimmune disorders. Yet their education and training falls several years and thousands of hours short of what physicians get.

…The AMA believes it is the responsibility of policymakers to ensure that naturopaths’ claims that they can treat a broad range of conditions are backed by facts—facts that include the specific education and training necessary to ensure patient safety.

________________

The AMA is clearly cautious here. A less polite statement might simply stress that naturopaths are taught a lot of nonsense which they later tend to administer to their unsuspecting patients. On this blog, we have repeatedly discussed the danger naturopaths present to public health in the US and elsewhere, e.g.:

Claims that naturopaths are a viable alternative to evidence-based medicine are wrong, irresponsible and dangerous. Regulators must be reminded that they have the duty to protect the public from charlatans and should therefore ensure that no false therapeutic or diagnostic claims can be made by naturopaths.

Dry needling is a therapy that is akin to acupuncture and trigger point therapy. It is claimed to be safe – but is this true?

Researchers from Ghent presented a series of 4 women aged 28 to 35 who were seen at the emergency department (ED) with post-dry needling pneumothorax between September 2022 and December 2023. None of the patients had any relevant medical history. All had been treated for a painful left shoulder, trapezius muscle or neck region in outpatient physiotherapist practices. At least three different physiotherapists were involved.

One patient presented to the ER on the same day as the dry needling procedure, the others presented the day after. All mentioned thoracic pain and dyspnoea. Clinical examination in all of these patients was unremarkable, as were their vital signs. Diagnosis was confirmed with ultrasound (US) and chest X-ray (CXR) in all patients. The latter exam showed left-sided apical pleural detachment with a median of 3.65 cm in expiration.

Two patients were managed conservatively. One patient (initial pneumothorax 2.5 cm) was discharged. The US two days later displayed a normally expanded lung. One patient with an initial apical size of 2.8 cm was admitted with 2 litres of oxygen through a nasal canula and discharged from the hospital the next day after US had shown no increase in size. Her control CXR 4 days later showed only minimal pleural detachment measuring 6 mm. The two other patients were treated with US guided needle aspiration. One patient with detachment initially being 4.5 cm showed decreased size of the pneumothorax immediately after aspiration. She was admitted to the respiratory medicine ward and discharged the next day. Control US and CXR after 1 week showed no more signs of pneumothorax. In the other patient, with detachment initially being 5.5 cm, needle aspiration resulted in complete deployment on US immediately after the procedure, but control CXR showed a totally collapsed lung 3 hours later. A small bore chest drain was placed but persistent air leakage was seen. Several trials of clamping the drain resulted in recurrent collapsing of the lung. After CT-scan had shown no structural deformities of the lung, suction was gradually reduced and the drain was successfully removed on the sixth day after placement. The patient was then discharged home. Control CXR 3 weeks later was normal.

The authors concluded that post-dry needling pneumothorax is, contrary to numbers cited in literature, not extremely rare. With rising popularity of the technique we expect complications to occur more often. Patients and referring doctors should be aware of this. In their informed consent practitioners should mention pneumothorax as a considerable risk of dry needling procedures in the neck, shoulder or chest region. 

The crucial question, in my view, is this: do the risks of dry-needling out weigh the risks of this form of therapy? Let’s have a look at some of the recent evidence that we discussed on this blog:

The evidence is clearly mixed and unconvincing. I am not sure whether it is strong enough to afford a positive risk/benefit balance. In other words: dry needling is a therapy that might best be avoided.

Microplastics are tiny polymer fragments that range from less than 0.2 inch to 1/25,000th of an inch. Smaller particles are called nanoplastics and are measured in billionths of a metre. Microplastics and nanoplastics (MNPs) are emerging as a potential risk factor for human health and for cardiovascular disease in particular. However, direct evidence that this risk extends to humans has so far been lacking. This investigation is a first step towards filling the gap.

The researchers conducted a prospective, multicenter, observational study involving patients who were undergoing carotid endarterectomy for asymptomatic carotid artery disease. The excised carotid plaque specimens were analyzed for the presence of MNPs with the use of pyrolysis–gas chromatography–mass spectrometry, stable isotope analysis, and electron microscopy. Inflammatory biomarkers were assessed with enzyme-linked immunosorbent assay and immunohistochemical assay. The primary end point was a composite of myocardial infarction, stroke, or death from any cause among patients who had evidence of MNPs in plaque as compared with patients with plaque that showed no evidence of MNPs.

A total of 304 patients were enrolled in the study, and 257 completed a mean (±SD) follow-up of 33.7±6.9 months. Polyethylene was detected in carotid artery plaque of 150 patients (58.4%), with a mean level of 21.7±24.5 μg per milligram of plaque; 31 patients (12.1%) also had measurable amounts of polyvinyl chloride, with a mean level of 5.2±2.4 μg per milligram of plaque. Electron microscopy revealed visible, jagged-edged foreign particles among plaque macrophages and scattered in the external debris. Radiographic examination showed that some of these particles included chlorine. Patients in whom MNPs were detected within the atheroma were at higher risk for a primary end-point event than those in whom these substances were not detected (hazard ratio, 4.53; 95% confidence interval, 2.00 to 10.27; P<0.001).

The authors concluded that, in this study, patients with carotid artery plaque in which MNPs were detected had a higher risk of a composite of myocardial infarction, stroke, or death from any cause at 34 months of follow-up than those in whom MNPs were not detected.

This is an impressive study – so much so that I report it here even though it has no connection to so-called alternative medicine, the focus of my blog. The fact that 58% of all plaques contained MNPs seems alarming. The finding that the presence of these MNPs is associated with a poor cardiovascular prognosis seems even more concerning.

MNPs have been found in every environmental compartment on earth. They are ingested not just by humans but by most animals as well. Even though research into these issues is most active, their effects are so far still under-researched and not fully understood.

The authors of the new investigation are rightly cautious: “Our data must be confirmed by other studies and on larger populations,” said Marfella, professor of internal medicine and director of the department of medical and surgical sciences at the University of Campania Luigi Vanvitelli in Naples, Italy. “However, our study convincingly highlights the presence of plastics and their association with cardiovascular events in a representative population affected by atherosclerosis.”

Of course, many questions are as yet unanswered but the subject is as worrying as it is important, e.g.:

  • Should exposure to MNPs be considered a cardiovascular risk factor?
  • What organs in addition to the heart may be at risk?
  • How can we reduce exposure?”

I wish I knew the ansers.

An article entitled “Homeopathy for worm infestations in children’s” caught my eye. Here is the un altered abstract:

Unusual sorts of worms can be there in a child’s stomach and may initiate several health complications such as pain, infection etc. To treat worm infections, one must identify about various categories of worms, and after understanding the kind of infection induced by the worm’s the treatment for the babies or children can planned. There are various Homeopathic medicines available which be used to treat worm infections without any side effects on the health of the children’s. In this paper we have discussed how the worm infection has been treated at our homeopathic research institute.

In the paper itself, the author, Dr. AK Dwivedi (Professor and H.O.D, Department of Physiology and Biochemistry, SKRP Guajarati Medical College, Indore, Madhya Pradesh, India), explains:

Homeopathic do not take care of just the disease, but is prescribed on the base of physical, emotional and genetic condition of a person. Homeopathic medicines act on both the mental and physical levels of individuals. Homeopathy is a natural and mild system of medicines that utilizes minute doses of well-researched remedies to improve the body’s natural curing procedure. Homeopathic medicines originate from substances that come’s from plants, minerals & animals.

The author’s conclusion is equally impressive:

On the basis of our research and after analysing the patients after medication we have found that homeopathy can completely cure the worm infection, If the dosages are properly prescribed and taken on that basis of investigation reports from time to time under guidance of experienced Homeopathic Physician worm infection can be treated with homeopathy effectively.

Yes, this level of incompetence could be quite funny! But sadly, it is also quite concerning. Most worm infestations are easily treated with effective conventional therapies. Untreated, they can have serious consequences. To advocate homeopathy – which is of course ineffective – is irresponsible, unethical and arguably criminal, in my view.

 

Here is the abstract of a recent article that I find worrying:

In 2020, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) challenged the world with a global outbreak that led to millions of deaths worldwide. Coronavirus disease 2019 (COVID-19) is the symptomatic manifestation of this virus, which can range from flu-like symptoms to utter clinical complications and even death. Since there was no clear medicine that could tackle this infection or lower its complications with minimal adverse effects on the patients’ health, the world health organization (WHO) developed awareness programs to lower the infection rate and limit the fast spread of this virus. Although vaccines have been developed as preventative tools, people still prefer going back to traditional herbal medicine, which provides remarkable health benefits that can either prevent the viral infection or limit the progression of severe symptoms through different mechanistic pathways with relatively insignificant side effects. This comprehensive review provides scientific evidence elucidating the effect of 10 different plants against SARS-CoV-2, paving the way for further studies to reconsider plant-based extracts, rich in bioactive compounds, into more advanced clinical assessments in order to identify their impact on patients suffering from COVID-19.

The conclusions of this paper read as follows:

…since these 10 herbs hold distinct bioactive compounds with significant properties in vitro and with remarkable benefits to human health, it is possible to prevent SARS-CoV-2 infection and reduce its symptomatic manifestations by consuming any of these 10 plants according to the recommended dose. The diversity in bioactive molecules between the different plants exerts various effects through different mechanisms at once, which makes it more potent than conventional synthetic drugs. Nonetheless, more studies are needed to highlight the clinical efficacy of these extracts and spot their possible side effects on patients, especially those with comorbidities who take multiple conventional drugs.

I should point out that the authors fail to offer a single reliable trial that would prove or even imply that any of the 10 herbal remedies can effectively treat or prevent COVID infections (to the best of my knowledge, no such studies exist). Laguage like “it is possible to prevent SARS-CoV-2 infection and reduce its symptomatic manifestations” is therefore not just misleading but highly dangerous and deeply unethical. Sadly, such evidence-free claims abound in herbal medicine.

I think the journal editor, the peer-reviewer, the authors and their universities ( University of Tripoli in Lebanon, American University of the Middle East, Egaila in Kuwait, University of Balamand, Kalhat, Tripoli in Lebanon, Lebanese University, Tripoli in Lebanon, Aix-Marseille Université in France) should be ashamed to produce such dangerous rubbish.

Traditional herbal medicine (THM) is frequently used in pediatric populations. This is perticularly true in many low-income countries. Yet THM has been associated with a range of adverse events, including liver toxicity, renal failure, and allergic reactions. Despite these concerns, its impact on multi-organ dysfunction syndrome (MODS) risk has so far not been thoroughly investigated.

This study aimed to investigate the incidence and predictors of MODS in a pediatric intensive care unit (PICU) in Ethiopia, with a focus on the association between THM use and the risk of MODS. It was designed as a single-center prospective cohort study conducted at a PICU in the university of Gondar Comprehensive Specialized hospital, Northwest Ethiopia. The researchers enrolled eligible patients aged one month to 18 years admitted to the PICU during the study period. Data on demographic characteristics, medical history, clinical and laboratory data, and outcome measures using standard case record forms, physical examination, and patient document reviews. The predictors of MODS were assessed using Cox proportional hazards models, with a focus on the association between traditional herbal medicine use and the risk of MODS.

A total of 310 patients were included in the final analysis, with a median age of 48 months and a male-to-female ratio of 1.5:1. The proportion and incidence of MODS were 30.96% (95% CI:25.8, 36.6) and 7.71(95% CI: 6.10, 9.40) per 100-person-day observation respectively. Renal failure (17.74%), neurologic failure (15.16%), and heart failure (14.52%) were the leading organ failures identified. Nearly one-third of patients (32.9%) died in the PICU, of which 59.8% had MODS. The rate of mortality was higher in patients with MODS than in those without. The Cox proportional hazards model identified renal disease (AHR = 6.32 (95%CI: 3.17,12.61)), intake of traditional herbal medication (AHR = 2.45, 95% CI:1.29,4.65), modified Pediatric Index of Mortality 2 (mPIM 2) score (AHR = 1.54 (95% CI: 1.38,1.71), and critical illness diagnoses (AHR = 2.68 (95% CI: 1.77,4.07)) as predictors of MODS.

The authors concluded that the incidence of MODS was high. Renal disease, THM use, mPIM 2 scores, and critical illness diagnoses were independent predictors of MODS. A more than twofold increase in the risk of MODS was seen in patients who used TMH. Healthcare providers should be aware of risks associated with THM, and educate caregivers about the potential harms of these products. Future studies with larger sample sizes and more comprehensive outcome measures are needed.

I do fully agree with the authors about the high usage of herbal and other so-called alternative medicines by children. We have shown that, in the UK the average one-year prevalence rate was 34% and the average lifetime prevalence was 42%. We have furthermore shown that the evidence base for these treatments in children is weak, even more so than for general populations. Finally, we can confirm that adverse effects are far from rare and often serious.

It is therefore high time, I think, that national regulators do more to protect children from SCAM practitioners who are at best uncritical about their treatments and at worse outright dangerous.

Guest post by Ken McLeod

This week a Coroner’s Inquest into the death of Jarrad Antonovich resumes [1] in Byron Bay, New South Wales, Australia. Meanwhile, pending the outcome of Inquests and other investigations, the NSW Health Care Complaints Commission has imposed interim prohibition order on Mr Soulore Solaris, ‘….a Counsellor who facilitates Ayahuasca ceremonies.’

Under section 41AA of the Health Care Complaints Act 1993 (Act), Mr Solaris: “….must not under any circumstances provide, or cause to be provided, any health services, either in paid employment or voluntary, to any member of the public.” [2] This applies until 11 March 2024, when the matter will be reconsidered.

So what is all this about? To go back a while, Mr Antonovich died from a perforated oesophagus after consuming ayahuasca and kambo frog toxin in October 2021, at the age of 46, while attending the ‘Dreaming Arts festival’, a six-day retreat at Arcoora near Kyogle in northern New South Wales. At the festival he had consumed ayahuasca and participated in a “Kambo” ceremony, involving secretions harvested from an Amazonian tree frog.

Ayahuasca is a psychedelic substance made from boiling plants that is used in ritualistic ceremonies in the Amazon basin. [3] Ayahuasca contains chemicals of concern, such as N,N-Dimethyltryptamine (DMT), a highly psychedelic substance and a Schedule I drug under the Convention on Psychotropic Substances. Ayahuasca is illegal in many countries, and it is illegal to sell, import, produce and possess it in Australia. [4]

Kambo is made from secretions harvested from an Amazonian tree frog. Kambo is usually used in a group setting, called a Kambo circle or Kambo ceremony. Wikipedia lists a whole smorgasbord of dangerous consequences, including tachycardia, nausea, vomiting, diarrhea, psychosis, SIADH, kidney damage (including acute renal failure), pancreas damage, liver damage including toxic hepatitis, dermatomyositis, esophageal rupture, seizures, and death. [5]

The Australian Therapeutic Goods Administration has listed it as a schedule 10 poison, in the category for “substances of such danger to health as to warrant prohibition of sale, supply and use”. [6]

Earlier in the Inquest we heard that:

  • – While Jarrad Antonovich‘s condition worsened there was resistance to calling for an ambulance. An ambulance was finally called at 11.30pm and took an hour to arrive because of the remote location.
  • -One ambulance officer reported that a female told them to “move away from Jarrad because it was affecting his aura” and no one told them he had consumed Kambo. [7]
  • -The event organiser Soulore “Lore” Solaris described Jarrad Antonovich’s death as ‘beautiful.’ [8]
  • -Fred Woller, the site manager at Arcoora, was unaware those running the event did not have any medical training. [9]
  • -Soulore “Lore” Solaris said Mr Antonovich ”…. had good support, a couple of kinesiologists with him and they couldn’t find anything wrong,” [10]
  • -Mr Antonovich “was surrounded by people who loved him and an Aboriginal elder called Uncle Andrew who was chanting sacred songs and calling the spirit out of his body” and “the koalas were making a special sound that is known to the elders when the land accepts a spirit”.
  • -“Mr Solaris has stated that he has plans to leave Australia for Brazil to visit his teachers.” [11]

We will keep you informed.

REFERENCES

  • 1 Court Lists http://tinyurl.com/3fzjd6uy
  • 2 Health Care Complaints Commission http://tinyurl.com/yh76rzc6
  • 3 The Guardian http://tinyurl.com/328manjt
  • 4 Wikipedia https://en.wikipedia.org/wiki/Legal_status_of_ayahuasca_by_country
  • 5 Wikipedia https://en.wikipedia.org/wiki/Kambo_(drug)
  • 6 The Guardian http://tinyurl.com/2s398psy
  • 7 The Guardian http://tinyurl.com/328manjt
  • 8 ABC http://tinyurl.com/5n7ejydy
  • 9 The Guardian http://tinyurl.com/59wa3rmn
  • 10 ABC http://tinyurl.com/5n7ejydy
  • 11 Byron Bay Echo http://tinyurl.com/44n78s2w

The French ‘National Assembly’ has yesterday adopted a major law aimed at reinforcing the prevention and combat against sectarian aberrations in France. This marks a significant step forward in strengthening the protection of citizens against abuse and manipulation by charlatans, gurus and other sectarian movements.

This bill, the result of particularly fruitful work and debate in both chambers, reflects the Government’s commitment to meeting the expectations of the victims of these sectarian movements.

Some of the key measures voted through by parliamentarians include:

  • The enshrinement in law of the powers of MIVILUDES (Interministerial Mission of Vigilance and Combat against Sectarian Aberrations);
  • The reinforcement of the penal response with the creation of the offence of placing or maintaining in a state of psychological or physical subjection;
  • The creation of an offence of incitement to abandon or refrain from treatment, or to adopt practices which clearly expose the person concerned to a serious health risk;
  • Support for victims, with the extension of the categories of associations that can bring civil action;
  • Information for the judiciary, with the introduction of an “amicus curiae” role for certain government departments in legal cases relating to cults.

Despite sometimes heated debates, particularly around article 4, fuelled by the opinion of the Conseil d’Etat, the adoption of this law by the National Assembly bears witness to a shared desire to protect the rights and freedoms of individuals while providing better protection for our fellow citizens against sectarian aberrations.

This bill is part of a multi-annual national strategy for 2023-2027 resulting from the conference on sectarian aberrations held in spring 2023. It is a major step towards strengthening the penal arsenal and protecting victims.

_______________

Sabrina Agresti-Roubache, Secretary of State for Citizenship and Urban Affairs, commented:

“Long-awaited by victim support associations, this text aims to strengthen our legal arsenal in the fight against sectarian aberrations. I’m delighted that all the articles have been adopted, particularly Article 4, which creates an offence of incitement to abandon or abstain from treatment. There have been some passionate debates in the Chamber, but I’d like to reiterate the basis of this bill: the State is not fighting against beliefs, opinions or religions, but against all forms of sectarian aberrations, these dangerous behaviors which represent a threat to our social cohesion and put lives at risk.”

_______________

Obviously, we shall have to see how the new law will be applied. But, in any case, it is an important step into the right direction and could put an end to much of so-called alternative medicine that endangers the health of French consumers.

Other nations should consicer following the Franch example.

Millions of US adults use so-called alternative medicine (SCAM). In 2012, 55 million adults spent $28.3 billion on SCAMs, comparable to 9% of total out-of-pocket health care expenditures. A recent analysis conducted by the US National Institutes of Health’s National Center for Complementary and Integrative Health (NCCIH) suggests a substantial increase in the overall use of SCAM by American adults from 2002 to 2022. The paper published in the Journal of the American Medical Association, highlights a surge in the use of SCAM particularly for pain management.

Data from the 2002, 2012, and 2022 National Health Interview Surveys (NHISs) were employed to evaluate changes in the use of 7 SCAMs:

  1. yoga,
  2. meditation,
  3. massage therapy,
  4. chiropractic,
  5. acupuncture,
  6. naturopathy,
  7. guided imagery/progressive muscle relaxation.

The key findings include:

  • The percentage of individuals who reported using at least one of the SCAMs increased from 19.2% in 2002 to 36.7% in 2022.
  • The use of yoga, meditation, and massage therapy experienced the most significant growth.
  • Use of yoga increased from 5% in 2002 to 16% in 2022.
  • Meditation became the most popular SCAM in 2022, with an increase from 7.5% in 2002 to 17.3% in 2022.
  • Acupuncture saw an increase from 1% in 2002 to 2.2% in 2022.
  • The smallest rise was noted for chiropractic, from 79 to 86%

The analyses also suggested a rise in the proportion of US adults using SCAMs specifically for pain management. Among participants using any SCAM, the percentage reporting use for pain management increased from 42% in 2002 to 49% in 2022.

Limitations of the survey include:

  • decreasing NHIS response rates over time,
  • possible recall bias,
  • cross-sectional data,
  • differences in the wording of the surveys.

The NCCIH researchers like such surveys and tend to put a positive spin on them, i.e. SCAM is becoming more and more popular because it is supported by better and better evidence. Therefore, SCAM should be available to everyone who wants is.

But, of course, the spin could also turn in the opposite direction, i.e. the risk/benefit balance for most SCAMs is either negative or uncertain, and their cost-benefit remains unclear – as seen regularly on this blog. Therefore, the fact that SCAM seems to be getting more popular is of increasing concern. In particular, more consideration ought to be given to the indirect risks of SCAM (think, for instance, only of the influence SCAM practitioners have on the vaccination rates) that we often discuss here but that the NCCIH conveniently tends to ignore.

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