TEDGlobal 2011
Ben Goldacre: Battling bad science
Ben Goldacre: til kamp mod dårlig videnskab
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Hver dag kommer nye råd for vores sundhed, men hvordan kan man vide om de er rigtige? Læge og epidemiolog Ben Goldacre giver en flyvende introduktion til hvordan beviser kan forvrænges - fra skærende åbenlyse kostrådgivningspåstande til de mere diskrete trick som lægemiddelindustrien benytter sig af.
Ben Goldacre - Debunker
Ben Goldacre unpicks dodgy scientific claims made by scaremongering journalists, dubious government reports, pharmaceutical corporations, PR companies and quacks. Full bio
Ben Goldacre unpicks dodgy scientific claims made by scaremongering journalists, dubious government reports, pharmaceutical corporations, PR companies and quacks. Full bio
Double-click the English transcript below to play the video.
00:15
So I'm a doctor, but I kind of slipped sideways into research,
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Så jeg startede som læge, men nu er jeg ligesom faldet sidelæns ind i forskning
00:18
and now I'm an epidemiologist.
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og nu er jeg epidemiolog.
00:20
And nobody really knows what epidemiology is.
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Og ingen ved rigtigt hvad epidemiologi er.
00:22
Epidemiology is the science of how we know in the real world
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Epidemiologi er videnskaben bag hvordan vi i virkeligheden ved,
00:25
if something is good for you or bad for you.
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om noget er godt for dig eller dårligt for dig.
00:27
And it's best understood through example
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Og det forstås bedst med for eksempel
00:29
as the science of those crazy, wacky newspaper headlines.
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videnskaben i de der skøre avisoverskrifter.
00:34
And these are just some of the examples.
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Her er bare et par eksempler
00:36
These are from the Daily Mail. Every country in the world has a newspaper like this.
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De her er fra Daily Mail. Alle lande har en avis af den slags.
00:39
It has this bizarre, ongoing philosophical project
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Den har det her bizarre filosofiske projekt
00:42
of dividing all the inanimate objects in the world
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hvor alle genstande i verden skal opdeles
00:44
into the ones that either cause or prevent cancer.
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i dem som forårsager og dem som beskytter mod kræft
00:47
So here are some of the things they said cause cancer recently:
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Her er nogle af de ting de har sagt forårsager kræft:
00:49
divorce, Wi-Fi, toiletries and coffee.
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skilsmisse, Wi-Fi, toiletartikler og kaffe.
00:51
Here are some of the things they say prevents cancer:
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Her er nogle af de ting de har sagt beskytter mod kræft:
00:53
crusts, red pepper, licorice and coffee.
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skorper, rød pepper, lakrids og kaffe
00:55
So already you can see there are contradictions.
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Så her kan du allerede se at det er modstridende
00:57
Coffee both causes and prevents cancer.
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Kaffe er både årsag og beskyttelse mod kræft
00:59
And as you start to read on, you can see
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Og når du læser videre, kan du se
01:01
that maybe there's some kind of political valence behind some of this.
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at der måske er noget politisk bagved det her
01:04
So for women, housework prevents breast cancer,
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Så for kvinder er husholdningsarbejde godt imod brystskræft
01:06
but for men, shopping could make you impotent.
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men for mænd kan shopping resultere i impotens
01:09
So we know that we need to start
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Så vi bliver nødt til at begynde
01:12
unpicking the science behind this.
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med at optrævle videnskaben bag det her
01:15
And what I hope to show
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Og det jeg håber at vise
01:17
is that unpicking dodgy claims,
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er at optrævling af snu påstande,
01:19
unpicking the evidence behind dodgy claims,
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optrævling af beviserne bag snu påstande,
01:21
isn't a kind of nasty carping activity;
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ikke bare er en slags ondsindet bagtalen -
01:24
it's socially useful,
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det er brugbart for samfundet
01:26
but it's also an extremely valuable
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og det er et ekstremt værdifuldt
01:28
explanatory tool.
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forklaringsværktøj
01:30
Because real science is all about
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Fordi rigtig videnskab handler om
01:32
critically appraising the evidence for somebody else's position.
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kritisk vurdering af beviser for andres påstande.
01:34
That's what happens in academic journals.
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Det er det som sker i akademiske tidskrifter
01:36
That's what happens at academic conferences.
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Det er det som sker ved akademiske konferenser
01:38
The Q&A session after a post-op presents data
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Spørgsmålene efter en forsker har præsenteret data
01:40
is often a blood bath.
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er ofte et rent blodbad
01:42
And nobody minds that. We actively welcome it.
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Og ingen har noget imod det. Vi er aktivt for det.
01:44
It's like a consenting intellectual S&M activity.
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Det er en slags accept af intellektuel sadomasochisme.
01:47
So what I'm going to show you
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Så det jeg nu vil vise jer
01:49
is all of the main things,
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er alle hovedpunkterne,
01:51
all of the main features of my discipline --
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alle hovedpunkterne fra mit felt -
01:53
evidence-based medicine.
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evidens-baseret medicin.
01:55
And I will talk you through all of these
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Og jeg vil guide jer gennem alle disse
01:57
and demonstrate how they work,
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og demonstrere hvordan de virker
01:59
exclusively using examples of people getting stuff wrong.
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kun ved hjælp af eksempler på folk som gør det på en forkert måde.
02:02
So we'll start with the absolute weakest form of evidence known to man,
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Så vi starter med den absolut svagest form for bevis vi kender til,
02:05
and that is authority.
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autoritet
02:07
In science, we don't care how many letters you have after your name.
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I videnskab, bryder vi os ikke om hvor mange bogstaver der er i din titel
02:10
In science, we want to know what your reasons are for believing something.
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I videnskab vil vi vide hvorfor du tror noget.
02:13
How do you know that something is good for us
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Hvordan du kan vide at noget er godt for os
02:15
or bad for us?
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eller dårligt for os?
02:17
But we're also unimpressed by authority,
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Men vi er også uimponerede af autoritet,
02:19
because it's so easy to contrive.
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fordi det er så nemt at finde på.
02:21
This is somebody called Dr. Gillian McKeith Ph.D,
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Hende her hedder Dr. Gillian McKeith Ph.D,
02:23
or, to give her full medical title, Gillian McKeith.
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eller hendes fuldstændige medicinske titel: Gillian McKeith
02:26
(Laughter)
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(latter)
02:29
Again, every country has somebody like this.
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Alle lander har en person som hende.
02:31
She is our TV diet guru.
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Hun er dietist guru på TV
02:33
She has massive five series of prime-time television,
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Hun har hele fem forskellige serier i bedste sendetid
02:36
giving out very lavish and exotic health advice.
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med rundhåndede og eksotiske helseråd.
02:39
She, it turns out, has a non-accredited correspondence course Ph.D.
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Det viser sig at hun har et ikke-autoriseret PhD-kursus
02:42
from somewhere in America.
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fra et eller andet sted i Amerika.
02:44
She also boasts that she's a certified professional member
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Hun kan også prale af at være certificeret medlem
02:46
of the American Association of Nutritional Consultants,
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af den Amerikanske Forening af Ernærings Konsulenter
02:48
which sounds very glamorous and exciting.
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hvilket lyder fortryllende og spændende.
02:50
You get a certificate and everything.
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Man får endda et certifikat og det hele
02:52
This one belongs to my dead cat Hetti. She was a horrible cat.
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Det her certifikat tilhører nu min døde kat Hetti. Hun var en forfærdelig kat.
02:54
You just go to the website, fill out the form,
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Man går bare ind på hjemmesiden og udfylder en formular,
02:56
give them $60, and it arrives in the post.
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giver dem 60 dollar, og så ankommer det med posten.
02:58
Now that's not the only reason that we think this person is an idiot.
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Det er nu ikke den eneste grund til at vi synes hun er en idiot.
03:00
She also goes and says things like,
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Hun går også rundt og siger ting som at
03:02
you should eat lots of dark green leaves,
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du bør spise masser af mørkegrønne blade
03:04
because they contain lots of chlorophyll, and that will really oxygenate your blood.
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fordi de indeholder masser af klorofyl som kan ilte dit blod
03:06
And anybody who's done school biology remembers
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Og enhver som har haft biologi i skolen husker
03:08
that chlorophyll and chloroplasts
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at klorofyl og kloroplaster
03:10
only make oxygen in sunlight,
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kun kan lave ilt når de får lys
03:12
and it's quite dark in your bowels after you've eaten spinach.
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og det er pænt mørkt i din mave efter at du har spist spinat.
03:15
Next, we need proper science, proper evidence.
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Derefter har vi brug for rigtig videnskab. Rigtige beviser.
03:18
So, "Red wine can help prevent breast cancer."
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Så, "rødvin kan hjælpe med at forhindre brystkræft".
03:20
This is a headline from the Daily Telegraph in the U.K.
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Det her er en overskrift fra the Daily Telegraph i England.
03:22
"A glass of red wine a day could help prevent breast cancer."
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"Et glas rødvin om dagen can hjælpe med at forhindre brystkræft"
03:25
So you go and find this paper, and what you find
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så du prøver at finde den her artikel, og det du finder
03:27
is it is a real piece of science.
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er faktisk et rigtigt stykke videnskab.
03:29
It is a description of the changes in one enzyme
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Det er en beskrivelse af forandringer som ses i et enzym
03:32
when you drip a chemical extracted from some red grape skin
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når du drypper et molekyle som er ekstraheret fra vindrueskind
03:35
onto some cancer cells
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på nogle kræftceller
03:37
in a dish on a bench in a laboratory somewhere.
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i en petriskål på et laboratoriebord et eller andet sted.
03:40
And that's a really useful thing to describe
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Og det er virkeligt brugbart at beskrive
03:42
in a scientific paper,
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i en videnskabelig artikel,
03:44
but on the question of your own personal risk
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Men for spørgsmålet om din egen personlige risiko
03:46
of getting breast cancer if you drink red wine,
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for at få brystkræft hvis du drikker rødvin
03:48
it tells you absolutely bugger all.
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siger det lige præcis ingenting overhovedet.
03:50
Actually, it turns out that your risk of breast cancer
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Det viser sig at risikoen for brystkræft
03:52
actually increases slightly
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faktisk stiger en smule
03:54
with every amount of alcohol that you drink.
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med hver eneste smule alkohol du drikker.
03:56
So what we want is studies in real human people.
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Så vi vil have studier i rigtige mennesker.
04:00
And here's another example.
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Her er et til eksempel.
04:02
This is from Britain's leading diet and nutritionist in the Daily Mirror,
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Det her er fra Englands førende diæt og kostvejleder i the Daily Mirror,
04:05
which is our second biggest selling newspaper.
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som er vores anden mest solgte avis.
04:07
"An Australian study in 2001
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"Et australsk studie fra 2001
04:09
found that olive oil in combination with fruits, vegetables and pulses
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fandt at oliven olie i kombination med frugter, grøntsager og grøntsagskerner
04:11
offers measurable protection against skin wrinklings."
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gav målbar beskyttelse mod rynker".
04:13
And then they give you advice:
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Og så giver de dig rådet:
04:15
"If you eat olive oil and vegetables, you'll have fewer skin wrinkles."
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"hvis du spiser oliven olie og grønsager, får du færre rynker".
04:17
And they very helpfully tell you how to go and find the paper.
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Og de beretter endda hvor du kan finde den videnskabelige artikel.
04:19
So you go and find the paper, and what you find is an observational study.
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når du så har fundet den her artikel, ser du at det er et observationsstudie.
04:22
Obviously nobody has been able
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Selvfølgeligt har ingen nogensinde kunnet
04:24
to go back to 1930,
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gå tilbage til 1930,
04:26
get all the people born in one maternity unit,
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fundet alle som blev født på én fødselsgang
04:29
and half of them eat lots of fruit and veg and olive oil,
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og fået halvdelen af dem til at spise masser af frugt, grønt og olivenolie,
04:31
and then half of them eat McDonald's,
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og den anden halvdel til at spise McDonalds
04:33
and then we see how many wrinkles you've got later.
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og derefter set hvor mange rynker de fik senere hen.
04:35
You have to take a snapshot of how people are now.
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De blev nødt til at tage et snapshot af hvordan folk var i dag.
04:37
And what you find is, of course,
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Og hvad de fandt var, selvfølgeligt
04:39
people who eat veg and olive oil have fewer skin wrinkles.
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at folk som spise grønsager og olivenolie havde færre rynker.
04:42
But that's because people who eat fruit and veg and olive oil,
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Men det er fordi folk som spiser frugt, grønt og olivenolie,
04:45
they're freaks, they're not normal, they're like you;
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de er underlige - de er ikke normale, de er som jer:
04:48
they come to events like this.
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de kommer til begivenheder som den her forelæsning.
04:50
They are posh, they're wealthy, they're less likely to have outdoor jobs,
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De er snobber, de er rige, og de har sandsynligvis ikke udendørs arbejde.
04:53
they're less likely to do manual labor,
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og de har mindre sandsyndlighed for at have hårdt arbejde
04:55
they have better social support, they're less likely to smoke --
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de har bedre social status, de har mindre sandsynlighed for at være rygere --
04:57
so for a whole host of fascinating, interlocking
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så for masser af fascinerende og sammenkædede
04:59
social, political and cultural reasons,
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sociale, politiske og kulturelle årsager
05:01
they are less likely to have skin wrinkles.
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har de mindre sandsynlighed for at have rynker.
05:03
That doesn't mean that it's the vegetables or the olive oil.
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Men det betyder ikke at det er grønsagerne eller olivenolien.
05:05
(Laughter)
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(latter)
05:07
So ideally what you want to do is a trial.
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Så ideelt set bør man lave et forsøg.
05:10
And everybody thinks they're very familiar with the idea of a trial.
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Og alle tror de ved hvad der menes med et forsøg
05:12
Trials are very old. The first trial was in the Bible -- Daniel 1:12.
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Ideen bag et forsøg er meget gammel. Det første er beskrevet i Biblen (Daniel 1:12)
05:15
It's very straightforward -- you take a bunch of people, you split them in half,
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det er meget simpelt - man tager en masse mennesker, og deler dem i to grupper
05:17
you treat one group one way, you treat the other group the other way,
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så gør man en ting ved en af grupperne og det modsatte ved den anden gruppe.
05:19
and a little while later, you follow them up
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og et stykke tid senere, finder man dem
05:21
and see what happened to each of them.
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og ser hvad der har sket med hver af dem.
05:23
So I'm going to tell you about one trial,
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Jeg vil fortæller jer om et forsøg,
05:25
which is probably the most well-reported trial
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som sandsynligvis er det mest omtalte forsøg
05:27
in the U.K. news media over the past decade.
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i de engelske medier i det seneste årti.
05:29
And this is the trial of fish oil pills.
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Det er afprøvningen af piller med fiskeolie.
05:31
And the claim was fish oil pills improve school performance and behavior
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Påstanden var at fiskeoliepiller forbedre både skolegang og opførsel
05:33
in mainstream children.
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i de fleste børn.
05:35
And they said, "We've done a trial.
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De sagde "vi har lavet et forsøg.
05:37
All the previous trials were positive, and we know this one's gonna be too."
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og alle de tidligere forsøg viste positive resultater, så vi ved at sådan bliver det her også"
05:39
That should always ring alarm bells.
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Det her bør altid få alarmerne til at ringe.
05:41
Because if you already know the answer to your trial, you shouldn't be doing one.
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For hvis man allerede kender svaret på dit forsøg, burde man ikke lave et forsøg.
05:44
Either you've rigged it by design,
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Enten er der fusket med designet,
05:46
or you've got enough data so there's no need to randomize people anymore.
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eller også findes der allerede så meget data at man ikke behøver at teste flere mennesker.
05:49
So this is what they were going to do in their trial.
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Her er hvad de havde tænk sig at gøre med deres forsøg.
05:52
They were taking 3,000 children,
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De tog 3000 børn.
05:54
they were going to give them all these huge fish oil pills,
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De skulle alle have de her kæmpemæssige fiskeoliepiller.
05:56
six of them a day,
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Seks af dem hver dag,
05:58
and then a year later, they were going to measure their school exam performance
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og et år senere skulle de så teste hvor dygtige de var i skolen.
06:01
and compare their school exam performance
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og disse testresultater skulle sammenlignes
06:03
against what they predicted their exam performance would have been
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med hvad man havde udregnet at deres resultater ville have været
06:05
if they hadn't had the pills.
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hvis ikke de havde fået fiskeoliepiller.
06:08
Now can anybody spot a flaw in this design?
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Er der nogen der kan se problemet med det studiedesign?
06:11
And no professors of clinical trial methodology
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Ingen professorer i klinisk forsøgsmetodologi
06:14
are allowed to answer this question.
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må svare på det her spørgsmål.
06:16
So there's no control; there's no control group.
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Der er ingen kontroller. Der er ingen kontrol gruppe.
06:18
But that sounds really techie.
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Ok, det lyder virkeligt teknisk.
06:20
That's a technical term.
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Og det er en teknisk term.
06:22
The kids got the pills, and then their performance improved.
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Børnene fik pillerne, og deres karakterer blev forbedret.
06:24
What else could it possibly be if it wasn't the pills?
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Hvad kunne overhovedet have været årsagen, hvis ikke pillerne?
06:27
They got older. We all develop over time.
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De blev ældre. Vi udvikler os alle med tiden.
06:30
And of course, also there's the placebo effect.
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Selvfølgelig er der også placeboeffekten.
06:32
The placebo effect is one of the most fascinating things in the whole of medicine.
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Placeboeffekten er en af de mest fascinerende ting i den medicinske videnskab.
06:34
It's not just about taking a pill, and your performance and your pain getting better.
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Det handler ikke bare om tage en pille og så klarer man sig bedre.
06:37
It's about our beliefs and expectations.
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Det handler om ens tro og forventninger.
06:39
It's about the cultural meaning of a treatment.
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Det handler om den kulturelle betydelse af at blive behandlet.
06:41
And this has been demonstrated in a whole raft of fascinating studies
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Det er blevet vist i masser af fascinerende studier
06:44
comparing one kind of placebo against another.
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som har sammenlignet en slags placebo med en anden slags.
06:47
So we know, for example, that two sugar pills a day
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Vi ved for eksempel at to sukkerpiller om dagen
06:49
are a more effective treatment for getting rid of gastric ulcers
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er et mere effektivt middel mod mavesår
06:51
than one sugar pill.
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en én sukkerpille.
06:53
Two sugar pills a day beats one sugar pill a day.
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To sukkerpiller slår én sukkerpiller om dagen.
06:55
And that's an outrageous and ridiculous finding, but it's true.
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Det er et uhyrligt og latterligt resultat, men det er sandt.
06:58
We know from three different studies on three different types of pain
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Vi ved fra tre forskellige studier af tre forskellige slags smerte
07:00
that a saltwater injection is a more effective treatment for pain
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at saltvandsindsprøjtninger er mere effektive mod smerte
07:03
than taking a sugar pill, taking a dummy pill that has no medicine in it --
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end sukkerpiller - altså snydepiller uden nogen som helst medicin i.
07:07
not because the injection or the pills do anything physically to the body,
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Ikke fordi indsprøjtningerne eller piller gør noget som helst ved kroppen,
07:10
but because an injection feels like a much more dramatic intervention.
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men fordi en sprøjte føles som en meget mere dramatisk behandling.
07:13
So we know that our beliefs and expectations
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Vi ved altså at vores tro og forventninger
07:15
can be manipulated,
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kan manipuleres.
07:17
which is why we do trials
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Hvilket er årsagen til at vi laver forsøg
07:19
where we control against a placebo --
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hvor vi kontrollerer mod placebo --
07:21
where one half of the people get the real treatment
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hvor halvdelen af alle får den virkelige behandling
07:23
and the other half get placebo.
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og den anden halvdel får placebo.
07:25
But that's not enough.
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Men det er ikke nok.
07:28
What I've just shown you are examples of the very simple and straightforward ways
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Hvad jeg har vist er eksempler på simple måder
07:31
that journalists and food supplement pill peddlers
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hvor journalister og kosttilskudssælgere
07:33
and naturopaths
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og naturlægemiddels-eksperter
07:35
can distort evidence for their own purposes.
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kan forvrænge beviser for deres egen vindings skyld.
07:38
What I find really fascinating
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Hvad jeg synes er virkelig fascinerende
07:40
is that the pharmaceutical industry
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er at den farmaceutiske industri
07:42
uses exactly the same kinds of tricks and devices,
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bruger de helt samme slags tricks og metoder
07:44
but slightly more sophisticated versions of them,
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bare i lidt mere sofistikerede versioner
07:47
in order to distort the evidence that they give to doctors and patients,
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så de kan forvrænge de beviser de giver til læger og patienter
07:50
and which we use to make vitally important decisions.
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og som vi bruger til at lave livsvigtige beslutninger.
07:53
So firstly, trials against placebo:
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For det første, forsøg med placebo:
07:55
everybody thinks they know that a trial should be
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alle tror de ved at et forsøg skal være
07:57
a comparison of your new drug against placebo.
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en sammenligning af et nyt lægemiddel med placebo.
07:59
But actually in a lot of situations that's wrong.
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Men det er faktisk forkert i mange situationer.
08:01
Because often we already have a very good treatment that is currently available,
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Fordi vi ofte har rigtigt gode behandlingsmuligheder allerede,
08:04
so we don't want to know that your alternative new treatment
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er vi ikke interesserede i at vide at den nye behandlingsmulighed
08:06
is better than nothing.
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er bedre end ingenting.
08:08
We want to know that it's better than the best currently available treatment that we have.
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Vi vil vide at den er bedre end den bedste behandlingsmulighed som allerede findes.
08:11
And yet, repeatedly, you consistently see people doing trials
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Og dog ser man igen og igen nogen som laver forsøg
08:14
still against placebo.
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mod placebo.
08:16
And you can get license to bring your drug to market
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Man kan få licens til at sælge lægemidler
08:18
with only data showing that it's better than nothing,
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bare med forsøgsresultater som viser at det er bedre end ingenting,
08:20
which is useless for a doctor like me trying to make a decision.
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hvilket er ubrugeligt for en læge som mig når jeg skal vælge medicin.
08:23
But that's not the only way you can rig your data.
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Men det er ikke den eneste måde man kan fuske med data.
08:25
You can also rig your data
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Man kan også fuske med data
08:27
by making the thing you compare your new drug against
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ved at sammenligne ens nye lægemiddel mod
08:29
really rubbish.
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noget bras.
08:31
You can give the competing drug in too low a dose,
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Man kan give det konkurrerende lægemiddel i for lav dosis,
08:33
so that people aren't properly treated.
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så folk ikke får korrekt behandling.
08:35
You can give the competing drug in too high a dose,
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Man kan give det konkurrerende lægemiddel i for høj dosis,
08:37
so that people get side effects.
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så folk får bivirkninger.
08:39
And this is exactly what happened
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Det er lige præcis det som er sket
08:41
which antipsychotic medication for schizophrenia.
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med antipsykotisk medicin mod skizofreni.
08:43
20 years ago, a new generation of antipsychotic drugs were brought in
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For 20 år siden blev en ny generation af antipsykotiske lægemidler lanceret
08:46
and the promise was that they would have fewer side effects.
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som lovede færre bivirkninger.
08:49
So people set about doing trials of these new drugs
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Så man bekyndte at lave forsøg med disse nye lægemidler
08:51
against the old drugs,
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mod de gamle lægemidler,
08:53
but they gave the old drugs in ridiculously high doses --
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men man ordinerede de gamle lægemidler i latterligt høje doser --
08:55
20 milligrams a day of haloperidol.
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20 milligram haloperidol om dagen.
08:57
And it's a foregone conclusion,
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Det en forudsigelig konklusion,
08:59
if you give a drug at that high a dose,
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at et lægemiddel med sådan en høj dosis,
09:01
that it will have more side effects and that your new drug will look better.
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vil have flere bivirkninger og at det nye lægemiddel vil se bedre ud.
09:04
10 years ago, history repeated itself, interestingly,
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For 10 år siden gentog historien interessant nok sig selv,
09:06
when risperidone, which was the first of the new-generation antipscyhotic drugs,
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da risperidone, hvilket var det første af en ny generation antipsykotiske lægemidler,
09:09
came off copyright, so anybody could make copies.
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ikke var dækket af patentet længere, og alle kunne lave kopier.
09:12
Everybody wanted to show that their drug was better than risperidone,
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Alle ville vise at deres lægemiddel var bedre end risperidone,
09:14
so you see a bunch of trials comparing new antipsychotic drugs
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så der kom en masse forsøg hvor man sammenlignede nye psykofarmaka
09:17
against risperidone at eight milligrams a day.
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mod risperidone, 8 milligram om dagen.
09:19
Again, not an insane dose, not an illegal dose,
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Igen, ikke en åndsvag dosis og ikke en ulovlig dosis,
09:21
but very much at the high end of normal.
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men dog helt sikkert i den høje ende af skalaen.
09:23
And so you're bound to make your new drug look better.
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På den måde er man sikker på at det nye lægemiddel ser bedre ud.
09:26
And so it's no surprise that overall,
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Og det er derfor ingen overraskelse at totalt set,
09:29
industry-funded trials
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har lægemiddelindustriens forsøg
09:31
are four times more likely to give a positive result
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fire gange så høj sandsynlighed for at give positive resultater
09:33
than independently sponsored trials.
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som uafhængigt finansierede forsøg.
09:36
But -- and it's a big but --
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Men -- og det er et stort "men" --
09:39
(Laughter)
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(latter)
09:41
it turns out,
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det viser sig,
09:43
when you look at the methods used by industry-funded trials,
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at når man kigger på forsøgsmetoderne som anvendes af lægemiddelindustrien
09:46
that they're actually better
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er de faktisk bedre
09:48
than independently sponsored trials.
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end uafhængigt finansierede forsøg.
09:50
And yet, they always manage to to get the result that they want.
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Og dog, får de altid de resultater de vil have.
09:53
So how does this work?
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Hvordan pokker går det til?
09:55
How can we explain this strange phenomenon?
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Hvordan kan vi forklare dette underlige fænomen?
09:58
Well it turns out that what happens
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Det viser sig at det som sker
10:00
is the negative data goes missing in action;
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er at negative data forsvinder;
10:02
it's withheld from doctors and patients.
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det skjules fra læger og patienter.
10:04
And this is the most important aspect of the whole story.
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Og det er det vigtigste aspekt ved det her.
10:06
It's at the top of the pyramid of evidence.
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Det er bare toppen af bevis-pyramiden.
10:08
We need to have all of the data on a particular treatment
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Vi bliver nødt til at få alle data for et givet lægemiddel
10:11
to know whether or not it really is effective.
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for at vide om det faktisk virker eller ej.
10:13
And there are two different ways that you can spot
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Der findes to forskellige metoder til at opdage
10:15
whether some data has gone missing in action.
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om data er blevet skjult.
10:17
You can use statistics, or you can use stories.
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Man kan bruge statistik eller man bruge beretninger.
10:20
I personally prefer statistics, so that's what I'm going to do first.
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Jeg foretrækker personligt statistisk, så det vil jeg starte med her.
10:22
This is something called funnel plot.
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Det her er noget som jeg kalder et funnel plot.
10:24
And a funnel plot is a very clever way of spotting
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Og et funnel plot er en smart metode til at opdage
10:26
if small negative trials have disappeared, have gone missing in action.
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hvis små negative forsøg har forsvundet, altså blevet skjult.
10:29
So this is a graph of all of the trials
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Her er et plot af alle forsøg
10:31
that have been done on a particular treatment.
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som har gjorts for et specifikt lægemiddel.
10:33
And as you go up towards the top of the graph,
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Når man ser mod toppen af hvert plot,
10:35
what you see is each dot is a trial.
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bemærk at hver prik er et forsøg,
10:37
And as you go up, those are the bigger trials, so they've got less error in them.
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når man ser mod toppen, findes de større forsøg, som har mindre fejlmargin.
10:40
So they're less likely to be randomly false positives, randomly false negatives.
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Så de har mindre sandsynlig for at give falsk positive eller falsk negative resultater.
10:43
So they all cluster together.
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Derfor grupperer de sig sammen.
10:45
The big trials are closer to the true answer.
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De større forsøg er nærmere et sandt svar.
10:47
Then as you go further down at the bottom,
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Når man så går nedad på plottet
10:49
what you can see is, over on this side, the spurious false negatives,
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kan man på venstre side se forsøg som er falsk negative af nogen tilfældig årsag,
10:52
and over on this side, the spurious false positives.
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og på højre side se forsøg som er falsk positive af nogen tilfældig årsag.
10:54
If there is publication bias,
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hvis der er publikations-bias
10:56
if small negative trials have gone missing in action,
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dvs. hvis små negative forsøgsresultater ikke er blevet offentliggjort,
10:59
you can see it on one of these graphs.
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kan man se det på det her funnel plot
11:01
So you can see here that the small negative trials
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Som man se her, har de små negative forsøgsresultater
11:03
that should be on the bottom left have disappeared.
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der burde være nederst til venstre, forsvundet.
11:05
This is a graph demonstrating the presence of publication bias
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Så det her plot demonstrerer at der er et publikationsbias
11:08
in studies of publication bias.
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i studier af publikationsbias.
11:10
And I think that's the funniest epidemiology joke
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Og det tror jeg faktisk er den sjoveste epidemiologijoke
11:12
that you will ever hear.
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nogensinde.
11:14
That's how you can prove it statistically,
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Det var den statistiske metode.
11:16
but what about stories?
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Men hvad med beretninger?
11:18
Well they're heinous, they really are.
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De er faktisk helt forfærdelige.
11:20
This is a drug called reboxetine.
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Der findes et lægemiddel som hedder reboxetine.
11:22
This is a drug that I myself have prescribed to patients.
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Jeg har selv ordineret det her lægemiddel til patienter.
11:24
And I'm a very nerdy doctor.
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Og jeg er endda en nørdet doktor.
11:26
I hope I try to go out of my way to try and read and understand all the literature.
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Sådan en som virkelig forsøger at læse og forstå alt relevant forskningslitteratur.
11:29
I read the trials on this. They were all positive. They were all well-conducted.
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Jeg har læst om de her forsøg. De var positive. De var velgennemførte.
11:32
I found no flaw.
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Jeg fandt ingen problemer.
11:34
Unfortunately, it turned out,
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Desværre viste det sig,
11:36
that many of these trials were withheld.
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at mange af de her forsøgsresultater blev skjult.
11:38
In fact, 76 percent
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76 procent, faktisk,
11:40
of all of the trials that were done on this drug
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af alle forsøg med det her lægemiddel
11:42
were withheld from doctors and patients.
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blev tilbageholdt fra læger og patienter.
11:44
Now if you think about it,
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Tænk på det her:
11:46
if I tossed a coin a hundred times,
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hvis jeg slår plat eller krone, hundrede gange,
11:48
and I'm allowed to withhold from you
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og jeg får lov til skjule fra jer
11:50
the answers half the times,
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hvad svaret var halvdelen af gangene,
11:52
then I can convince you
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så kunne jeg nok overbevise jer
11:54
that I have a coin with two heads.
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om at jeg havde en mønt med to krone-sider.
11:56
If we remove half of the data,
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Hvis vi fjerner halvdelen af alt data,
11:58
we can never know what the true effect size of these medicines is.
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kan vi aldrig nogensinde vide hvad den virkelig effekt af lægemidler er.
12:01
And this is not an isolated story.
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Og det her er ikke en enkeltstående beretning.
12:03
Around half of all of the trial data on antidepressants has been withheld,
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Ca. halvdelen af alle forsøgsresultater for antidepressiv medicin er aldrig offentliggjort
12:07
but it goes way beyond that.
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og det går langt videre end det.
12:09
The Nordic Cochrane Group were trying to get a hold of the data on that
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Det Nordiske Cochrane Center i København prøvede at få adgang til data
12:11
to bring it all together.
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som kunne sammenfatte det hele.
12:13
The Cochrane Groups are an international nonprofit collaboration
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Cochrane centre er internationale nonprofit-samarbejder
12:16
that produce systematic reviews of all of the data that has ever been shown.
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der laver systematiske gennemgange af alle forsøgsdata som nogensinde er blevet lavet.
12:19
And they need to have access to all of the trial data.
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De har brug for adgang til alle forsøgsdata.
12:22
But the companies withheld that data from them,
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Men lægemiddelindustrien tilbageholdte data fra dem,
12:25
and so did the European Medicines Agency
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og det gjorde det Europæiske Medicin Agentur også
12:27
for three years.
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i tre år.
12:29
This is a problem that is currently lacking a solution.
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Det her er et problem som vi mangler en løsning på.
12:32
And to show how big it goes, this is a drug called Tamiflu,
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For at vise hvor stort det her er, så findes der et lægemiddel ved navn Tamiflu
12:35
which governments around the world
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som regeringer verden over
12:37
have spent billions and billions of dollars on.
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har spenderet millliarder og millarder dollars på.
12:39
And they spend that money on the promise
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Og pengene bruges på det præmis
12:41
that this is a drug which will reduce the rate
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at det her lægemiddel vil reducere
12:43
of complications with flu.
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komplikationsraten ved influenza.
12:45
We already have the data
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Vi har allerede forsøgsresultater
12:47
showing that it reduces the duration of your flu by a few hours.
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som viser at the kan forkorte en influenza med et par timer.
12:49
But I don't really care about that. Governments don't care about that.
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Men det er jeg ligeglad med. Regeringer er ligeglade med det.
12:51
I'm very sorry if you have the flu, I know it's horrible,
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Jeg er virkelig ked af det hvis du har influenza, det er skrækkeligt,
12:54
but we're not going to spend billions of dollars
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men vi skal ikke spendere millarder af dollars
12:56
trying to reduce the duration of your flu symptoms
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for at forkorte influenzasymptomerne
12:58
by half a day.
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med en halv dag.
13:00
We prescribe these drugs, we stockpile them for emergencies
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De her lægemidler skal anvendes og indkøbes til nødstilfælde
13:02
on the understanding that they will reduce the number of complications,
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på det præmis at de kan reducere antallet af komplikationer
13:04
which means pneumonia and which means death.
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hvilket her betyder lungebetændelse og død.
13:07
The infectious diseases Cochrane Group, which are based in Italy,
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Cochrane Centeret for smitsomme sygdome, med hovedkvarter i Italien,
13:10
has been trying to get
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har forsøgt at få
13:12
the full data in a usable form out of the drug companies
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fuldstændig data i en brugbar form ud af lægemiddelindustrien
13:15
so that they can make a full decision
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så de kan lave en fuldstændig analyse
13:18
about whether this drug is effective or not,
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af om det her lægemiddel er effektivt eller ej.
13:20
and they've not been able to get that information.
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Og de har ikke kunne få de data.
13:23
This is undoubtedly
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Det her er utvivlsomt
13:25
the single biggest ethical problem
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det største etiske problem
13:28
facing medicine today.
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i medicinens verden i dag.
13:30
We cannot make decisions
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Vi kan ikke lave beslutninger
13:33
in the absence of all of the information.
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når vi mangler fuldstændig information.
13:37
So it's a little bit difficult from there
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Så herfra er det lidt svært
13:40
to spin in some kind of positive conclusion.
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at skabe en positiv konklusion på det her foredrag.
13:44
But I would say this:
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Men det her vil jeg god sige:
13:48
I think that sunlight
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Jeg tror at sollys
13:51
is the best disinfectant.
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er det bedste desinfektionsmiddel.
13:53
All of these things are happening in plain sight,
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Alle de her ting sker åbent for alle at se,
13:56
and they're all protected
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men de er beskyttede
13:58
by a force field of tediousness.
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af et skjold af langsommelighed
14:01
And I think, with all of the problems in science,
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og jeg tror, med alle videnskabens problemer,
14:03
one of the best things that we can do
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at en af de bedste ting vi kan gøre
14:05
is to lift up the lid,
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er at åbne låget
14:07
finger around in the mechanics and peer in.
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og pille lidt rundt med mekanikken bag det hele.
14:09
Thank you very much.
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Mange tak.
14:11
(Applause)
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(klapsalver)
Reviewed by Jonas Tholstrup Christensen
ABOUT THE SPEAKER
Ben Goldacre - DebunkerBen Goldacre unpicks dodgy scientific claims made by scaremongering journalists, dubious government reports, pharmaceutical corporations, PR companies and quacks.
Why you should listen
"It was the MMR story that finally made me crack," begins the Bad Science manifesto, referring to the sensationalized -- and now-refuted -- link between vaccines and autism. With that sentence Ben Goldacre fired the starting shot of a crusade waged from the pages of The Guardian from 2003 to 2011, on an addicitve Twitter feed, and in bestselling books, including Bad Science and his latest, Bad Pharma, which puts the $600 billion global pharmaceutical industry under the microscope. What he reveals is a fascinating, terrifying mess.
Goldacre was trained in medicine at Oxford and London, and works as an academic in epidemiology. Helped along by this inexhaustible supply of material, he also travels the speaking circuit, promoting skepticism and nerdish curiosity with fire, wit, fast delivery and a lovable kind of exasperation. (He might even convince you that real science, sober reporting and reason are going to win in the end.)
As he writes, "If you're a journalist who misrepresents science for the sake of a headline, a politician more interested in spin than evidence, or an advertiser who loves pictures of molecules in little white coats, then beware: your days are numbered."
Ben Goldacre | Speaker | TED.com