From the only humanist, atheist, skeptic rock star out there, Tim Minchin!
From the only humanist, atheist, skeptic rock star out there, Tim Minchin!
I have been involved in a number of discussions lately regarding the concept of testing antibody titers in lieu of vaccinating, and I thought it might be useful to summarize some of the issues involved in this complex topic. I will briefly explain the basic biology of immunization and then talk about the issues surrounding the usefulness of vaccine antibody titers.
How Vaccination Works
The immune system has many mechanisms for identifying and destroying infectious organisms, such as bacteria and viruses, in order to prevent or control disease. The details are bewilderingly complicated, and entire courses, even entire careers in science, are focused on trying to understand how this process works. There are a number of web sites that offer simple overviews of how vaccination stimulates the immune system to protect against infectious organisms (e.g. National Institutes of Health, Centers for Disease Control, National Network for Immunization Information).
Briefly, when a virus or bacterium invades the body, specialized cells that are part of the immune system begin to attack it. Some of these fight off the organism directly, but others communicate with the rest of the immune system to stimulate a host of different responses throughout the body. Part of this global reaction is a memory response. After an initial infection and illness, the immune system learns to recognize the organism so if it sees it again in the future, it can mount a faster and more effective response. Sometimes, this memory provides complete and lifelong immunity. However, sometimes, this immunity is incomplete or only temporary. The difference depends on a lot of factors involving the type of infectious organism and the individual’s immune system.
Vaccines teach the immune system to recognize an infectious organism without producing the actual illness. Usually, vaccines use a killed or weakened version of the infectious organism so the immune system can learn to recognize it without an actual infection and illness. In the future, then, the immune system of a vaccinated individual will be able to generate a faster, stronger protective response to the real organism, therefore avoiding an infection. Again, the effectiveness of vaccination and the duration of this immunity to infection vary and depend on many factors.
There are two basic components to the immune system’s memory of a disease-causing organism. One, called humoral immunity, involves producing proteins called antibodies. These are proteins that recognize a particular organism and help the body to fight it. Antibodies are produced for almost every organism we encounter, naturally or through vaccination, so we all make antibodies to thousands of organisms all the time. We can also get some antibodies from our mothers as babies, through nursing.
The other aspect of the memory response is called cell-mediated immunity. This involves special cells in the immune system which learn to recognize and attack invading microorganisms.
So when we talk about measuring antibody titers, we mean that we are measuring the amount of antibodies in the bloodstream which are produced in response to infection or vaccination for a single microorganism. If we have had an infection or vaccine in the past, we will often have antibodies against that particular organism. These may last for weeks, months, or years. It is important to realize, however, that having antibodies does not always mean we are immune to an infectious organism. If we have too few antibodies, we may be susceptible. And in the case of some organisms, having antibodies is not enough to fully protect us, so we may be susceptible no matter how many we produce. And since we produce antibodies during an infection, having them may not mean we have been vaccinated or had past exposure to an infectious disease, they may simply mean we are currently infected with that disease!
The challenge, then, in using antibody levels to make decisions about vaccination is that the significance of the measurement depends on the details of the biology of the particular organism. When we talk about antibodies and vaccination, we have to talk about one specific disease at a time, because the rules that apply to one disease won’t necessarily apply to another.
Core Vaccines & Antibody Titers
As I mentioned above, for some diseases antibody titers don’t represent immunity or susceptibility very well. Antibodies to common cat disease, for example, such as Feline Herpes Virus (FHV) or Feline Leukemia Virus (FeLV), don’t correlate well with protection against infection. A cat with a high antibody titer against FHV may very well still be susceptible to infection and may benefit from vaccination. And a cat with a high titer for FeLV is probably already permanently infected rather than immune. Antibody titers for rabies and Feline Panleukopenia, however, do correlate with immunity against these diseases.
For dogs, the most important core vaccines are for Canine Distemper Virus (CDV), Canine Parvovirus (CPV), and Rabies. In the case of these diseases, a high antibody titer does usually mean the dog is immune, which would mean additional vaccination for those diseases is not needed at the time the titer is measured. However, the rate at which individuals lose immunity to specific diseases varies quite a bit, so there is no way to predict based on a single titer when that individual will become susceptible again or need additional vaccination.
What most people don’t realize is that while a high titer for some disease, such as CDV, CPV, and Rabies, means a dog is probably immune, a low titer does NOT mean the dog is susceptible and needs to be vaccinated. That is because the other component of the immune system’s memory response, cell-mediated immunity, can protect against infection sometimes even when measured titer levels are low.
So a positive or high titer may mean no vaccine is needed right now, but a low titer does not mean a dog should be vaccinated. In the case of a low titer, we have no way of knowing if that dog is susceptible to these diseases or not.
Specific Titer Tests
You may wonder how we know whether or not a certain level of antibodies measured in the blood mean that individual is protected against that disease. The answer is that the only way to know is through challenge testing. This means that we have to measure antibody levels in a number of individuals with a variety of different titers, then try to infect them with the specific disease we are studying and see which ones get sick and which don’t. This is how cutoff levels for antibody titers have been determined for CDV, CPV, Rabies, and other canine and feline vaccine-preventable disease.
This kind of challenge testing may only be accurate for a specific titer testing method. So if two different laboratories use two different types of titer test, the titer level that is protective will be different, and both would need to do challenge testing to figure out what titer level is protective for the specific test method they each use
Obviously, there are ethical issues associated with this kind of research, and so very little of it is done any more. Most titer tests available have not been validated by challenge testing but have simply been compared to tests which have. This may mean that the values used to determine if an individual is immune to a particular disease are accurate, but it is also possible that they are not. So there is usually some uncertainty about what a “protective” titer really means.
As an example, one popular in-house antibody test sold to veterinarians is called Vaccicheck. This test provides a simple measure of roughly how much antibody an individual dog has against CDV, CPV, and also Canine Infectious Hepatitis. Again, no challenge studies have been done to validate the specific cutoff this test uses, but the test has been compared to what are considered “gold-standard” titer tests. For the canine Vaccicheck test, here are the results of one such study:
B.A. Butler; P.C. Crawford . Accuracy of a Point-of-Care Immunoassay to Determine Protective Antibody Titers For Canine Parvovirus and Canine Distemper Virus. ACVIM Forum, 2013.
Immunoassay sensitivity was 97% for CDV and 99% for CPV. Specificity was 75% for CPV and 79% for CDV. Many of the false positive reactions were in samples with antibody titers near the reference laboratory PAT cutoff. Overall diagnostic accuracy was 90% for CDV and 94% for CPV.
Sensitivity, specificity, and both positive and negative predictive value are somewhat complex statistical topics. Basically, this study showed that when the Vaccicheck test indicated a negative result (low titer level), this was very accurate. Of course, this result doesn’t help us make vaccination decisions because it doesn’t tell us whether or not the individual is vulnerable to infection since cell-mediated immunity may still be providing protection.
The accuracy of a positive result (high titer level) was also pretty good, but not nearly as good as that of a negative level. This means that some dogs will have a positive test, suggesting they are protected, when they really don’t have a high level of antibodies and may or may not actually be immune.
So overall, this test will usually tell us when a dog has a high CDV or CPV titer and does not need to be vaccinated, though it will get some of these wrong. It will more reliably tell us when a dog has a low titer level, but that doesn’t help much us decide if that dog needs to be vaccinated or not. Generally, other in-house titer tests have similar pros and cons. You can see that it can be difficult to make vaccination decisions based on this kind of test.
Legal Issues
The legal requirements for vaccination vary by county and even municipality, so it is difficult to make accurate generalizations. Most jurisdictions only require proof of vaccination against rabies, since that is the disease of greatest concern with respect to human health. Most jurisdictions also do not allow titer testing in lieu of vaccination for rabies, though some may. And when titers are used, the only test that is usually accepted is the FAVM from the Kansas State University veterinary laboratory. So while titers are representative of immunity for rabies in dogs and cats, and thus can indicate when vaccination is not needed, they are not often useful practically because they don’t fulfil the legal vaccination requirements.
Titers may or may not be accepted by other parties that require vaccination for other diseases, such as boarding kennels, training facilities, and dog show organizers. Which tests, if any, are accepted is up to the individual organization. So titers may not always be useful in avoiding vaccination if we are vaccinating specifically to meet a legal or institutional requirement.
Vaccine Safety
I have written many times about the subject of vaccine safety. While I believe in avoiding unnecessary vaccination, and while my own recommendations to clients often lead to less frequent vaccination than commonly practiced or suggested in some guidelines, I believe that the fear of vaccines that leads many people to desire to reduce vaccination is unjustified. Vaccines are very, very safe, and many of the specific concerns, such as mercury in vaccines, and autoimmune disease from vaccination, are unproven, exaggerated, or just plain untrue. So while I believe the evidence indicates we can safely vaccinate most dogs and cats far less often than has traditionally been recommended, I do not believe we should use titers or other methods to reduce vaccination out of fear.
Children in the United States and Europe are experiencing a growing risk of preventable infectious disease, and the real harm that comes from such infections, specifically because of a decrease in compliance with sound, evidence-based vaccination recommendations. Mumps, measles, and whooping cough, for example, are injuring and killing children who could have been protected, due mostly to fears among parents which are based on misconceptions or lies. I believe we must be very careful not to follow this same path in veterinary medicine.
So while I see utility for antibody titer testing in some situations, it is distressing that some companies selling these tests seem to be marketing them using fear and the testimonials of individuals who are known opponents of science-based medicine and promoters of irrational anti-vaccine positions and unscientific alternative therapies. Dr. Shawn Messonier, Dr. Karen Becker, Catherine O’Driscoll, and Dogs Naturally Magazine, are some of the entirely unreliable sources to which the Vaccicheck company refers pet owners in promoting their product. We will do far more harm than good for our pets if we base our vaccination decisions on pseudoscience or irrational fear, which is what these individuals often promote, rather than sound science.
Additional Information
Ford, RB. Antibody titers versus vaccination. Today’s Veterinary Practice. May/June, 2013.
2. Here is the American Animal Hospital Association (AAHA) Canine Vaccination Guidelines, which talks specifically and in detail about particular vaccines and comprehensively reviews the available evidence on efficacy, safety, and duration of immunity. The guidelines specifically address titers and generally recommend some uses of them:
Despite the confusion and controversy surrounding antibody testing, these serologic tests are useful for monitoring immunity to CDV, CPV-2, CAV-1, and RV…. The tests are also medically useful to ensure that a dog responds to a specific core virus vaccine and/or to determine if immunity is present in a previously vaccinated dog. Those tests are also used to demonstrate protective immunity as well as DOI.
3. The American Veterinary Medical Association (AVMA) Report on Cat and Dog Vaccines also addresses the subject of titers, but the conclusion is somewhat different from the AAHA guidelines:
…it is currently impossible to determine the immune status of an animal relative to all the infectious diseases of concern without conducting challenge testing. Further, serologic results do not appear to be a sensitive indicator of immune response for some diseases or vaccines in cats and dogs. It was concluded that there are variations within and among laboratories, as well as a lack of validated sensitivity, specificity, and confidence intervals, leading to the conclusion that serologic testing is generally unreliable….
…higher serologic titers are generally associated with greater resistance, but…it is possible for an animal with no titer for a specific organism to have solid resistance to challenge. Conversely, an animal with a titer that is generally regarded as protective for a specific organism may also become ill as the result of challenge, possibly because of overwhelming exposure or immune suppression…
…practitioners are cautioned to consider carefully whether the test proposed has been appropriately validated, thereby providing a predictive value for whether the animal needs to be revaccinated, and includes confidence intervals to help the practitioner determine the risks and benefits of relying on the test results. Practitioners should also determine whether a selected laboratory has a quality control program sufficient to make the test results reliable.
4. The American Association of Feline Practitioners (AAFP) has also issued guidelines for vaccination of cats. These guidelines only comment briefly on the use of antibody titers (also called serology):
It is important to be aware that a variety of methods…are utilized to determine titers.…Titer results in individual cats determined at the same point in time, therefore, may vary depending on the methodology used. When electing to submit serum for antibody titers, it needs to be appreciated that a ‘positive’ antibody titer result obtained on one day is not necessarily predictive of a ‘positive’ titer at any point in the future.
In general, cats having a ‘positive’ antibody titer against FPV are immune. In fact, the protective immunity that develops following FPV vaccination is expected to be sustained for several years. By contrast, serum antibody titers for FHV-1 and FCV may not necessarily correlate well with protective immunity and should not be used to predict protection in the future. Antibody titers to FeLV and FIV do not correlate with immunity and should not be used to determine the need for vaccination. Although feline rabies titers can be determined (by a certificated laboratory) in individual animals, a rabies titer is only an indication of serological response to vaccination. Rabies titers are not recognized as an index of immunity.
In addition, the absence of significant levels of antibody (a ‘negative’ titer) is not necessarily an indication of susceptibility… In some diseases (eg, FHV-1), cell-mediated immunity is important and a cat may be immune even though no antibodies are detectable.
Because antibody titers may not reliably correlate with, or predict, the degree of protection or susceptibility for an individual cat, the Advisory Panel recommends employing defined revaccination intervals rather than measuring antibody titers to assure protection.
Bottom Line
Vaccine titers can tell us an individual is immune and does not need to be vaccinated for some specific diseases. For other diseases, a positive titer does not reflect immunity. And a negative titer cannot reliably tell us if an individual is susceptible and need additional vaccination. Therefore, the usefulness of titers in determining if an individual needs to be vaccinated is quite limited. This usefulness is further dependent on the specific kind of titer test used and how it has been validated.
Titers can lead to a reduction in unnecessary vaccination in some cases, if an individual has a titer that can be identified as representative of immunity. However, titers can also lead to an increase in unnecessary vaccinations if animals with negative titers are routinely vaccinated even though they may already be immune.
Titers cannot generally be substituted for legal vaccination requirements, particularly for vaccination against rabies
The vaccines we use are extremely safe, so we have to remind ourselves and our clients that when in doubt it is probably far safer to vaccinate than not to vaccinate, unless there is some know history of adverse vaccine reaction, autoimmune disease, etc. The resurgence of vaccine-preventable disease in children following the decline in vaccination rates is well-demonstrated, and we don’t want to go down that road.
Using scientific evidence concerning the duration of protective immunity following vaccination in a population, and the existing guidelines based on this evidence, is probably a more appropriate strategy for determining how often to vaccinate individuals than is the routine use of antibody titers. Current guidelines for specific vaccines are based on a comprehensive review of existing evidence, and they can be updated as new evidence emerges. While titers may have use in some specific situations, they are not a simple, universal substitute for rational, science-based vaccination guidelines, and they do not offer as reliable an “individualization” of vaccination recommendations as some promoters suggest.
I’ve written frequently about probiotics, microorganisms given as supplements to hopefully benefit health. Often claimed as an “alternative” therapy, probiotics are really no different from any therapy in science-based medicine. The theory behind their use is certainly consistent with established scientific knowledge. Microorganisms are undoubtedly important in health and disease for humans and most other animals. And there is significant in vitro and lab animal research to suggest some value to the use of probiotics. Finally, there is some limited clinical evidence for the safety and efficacy of some probiotics for some health issues in human and veterinary patients.
However, there are also problems with probiotics as a medical therapy. The natural microbial ecosystem of every individual is different, and the flora of different species is often quite dissimilar. We know very little about the type and role of most of the hundreds of species of microorganisms that live in and on most animals. Whether a particular probiotic organism helps, harms, or does nothing at all in a given patient depends on many factors, most of which we are still quite ignorant about. So our ability to utilize the potential of probiotic therapy is rudimentary for now, and it will only improve as we do the laborious work of building our knowledge and understanding.
Probiotic therapy is also hampered by the lack of regulatory oversight, especially here in the U.S. Several research studies have shown that the majority of probiotic products on the market are mislabeled and often contain nothing resembling what is on the label. A ridiculous proportion of these products contain no living organisms at all, and so are in no real sense even probiotics. The dramatic claims often made for such products are almost never justified given the limited evidence and abysmal quality control for most probiotic products.
This month’s issue of the Journal of Veterinary Internal Medicine has an excellent article on the subject of probiotics in veterinary medicine. Though this article focuses on probiotics for horses, a species I do not treat in practice, in touches on many important issues concerning probiotics that are also relevant to probiotics for dogs, cats, and other veterinary species.
Schoster, A. Weese, J.S. and Guardabassi. L. Probiotic Use in Horses – What is the Evidence for Their Clinical Efficacy? J Vet Intern Med 2014;28:1640–1652
The authors give a nice overview about the kinds of organisms that are most appropriate for use as probiotics. The usual criteria include the ability to survive passage through the acid environment of the stomach and commercial processing, adhere to cells in the GI tract, and have a measurable, beneficial effect on the patient. The available evidence they cite suggests that a probiotic organism need not necessarily come from the species in which it is to be used, though there is some debate about this.
The authors also mention a criterion often overlooked, especially by those who claim probiotics are inherently safe because they are “natural.” Microorganisms can share genetic material, and one type of gene sharing that can create significant harm is the transfer of antiobiotc resistance genes. If a probiotic organism has resistance to antibiotics and conveys this to another organism in the gut that can cause disease, this will make treatment of that disease more difficult if it develops. In Europe, regulators require probiotic product be tested for such antibiotic resistance, but this is not the case in the U.S.
The authors also cover the primary mechanisms of action proposed for probiotics: immune system modulation, production of antimicrobial substances, out-competing potentially harmful microorganisms in the gut ecosystem, and inhibition or inactivation of toxins produced by other organisms. The diversity of effects, and the differences between organisms, illustrate the complexity of such biological therapies, and why simple, general rules about “good” and “bad” organisms aren’t very reliable.
The authors discuss the issues of poor quality control and inadequate regulatory oversight, which I have already mentioned.
The article also covers the always-important question of safety. Few adverse effects have been reported in people or animals taking probiotics, but it is unclear what the real risks are at this point. For one thing, many probiotic products, as I have already mentioned, are mislabeled. If they don’t contain any appreciable quantity of live organisms, they of course aren’t likely to have any harmful effects, but they aren’t likely to have any positive effects either. For this reason, the absence of reports of harm may reflect the absence of any effect at all for many probiotic products. At least some negative effects have been reported, in humans and in other animals, so while these products are probably pretty low risk, there are likely some circumstances and individuals in which they can cause harm, and more research is needed o understand the risks.
Lastly, the article covers the clinical studies of probiotics in horses to date. Only eight studies are cited, with a mix of positive and negative results. Some studies showed beneficial effects, but many showed either no difference from placebo or effects on some outcome measures and not others. And at least one reported a negative effect. The overall evidence suggests some possible value to probiotic therapy, but at this time the risks and benefits are largely unknown. The authors conclusions are these:
Although probiotics have shown promise in the treatment of selected diseases in humans, the evidence that they can be used to control diseases in horses so far is weak.
Based on lack of regulation regarding quality control of commercial products, use of over-the-counter products is questionable, particularly in the absence of scientific information on safety and clinical efficacy.
Despite all of these limitations, probiotics generally are regarded as safe, cost effective and easy to administer. Therefore, additional research is warranted to test possible applications in equine veterinary practice.
Very similar conclusions likely apply to the use of probiotics in small animals. They are probably low risk and are relatively easy to use and inexpensive. In most cases, there is little evidence that they have significant benefits, but their use for some conditions, such as diarrhea, is reasonable given the limited but suggestive evidence available so far.
Unfortunately, most products are probably unreliable in quality, so those used should be ones from reputable companies that have demonstrated reasonable labeling accuracy (for example, Iams’ Prostora and Purina’s Fortiflora).
More research is certainly needed, and I am hopeful that as it is done more and better evidence will be available to support specific uses of particular probiotic organisms for particular problems. At this time, however, excessively broad or confident claims are, as always, unjustified, and we need to be clear with our clients that there is a lot of uncertainty and guesswork in our use of probiotics.
As I’ve often pointed out, the majority of the information on complementary and alternative therapies for pets available on the internet comes from companies or advocates selling these products and services. One of the reasons I write this blog is to make sure that the skeptical and evidence-based perspective on these practices is available for people to consider and to balance against the marketing and hype. And because this perspective is inherently less appealing to most people than optimistic anecdotes and testimonials, and since it draws a fair bit of hostile response, there are few individuals available to provide this point of view.
Because of this, I am often approached by journalists who are looking for someone willing to provide a skeptical “balance” to articles in the media about alternative veterinary therapies. The articles themselves, unfortunately, are often quite credulous or play to the heartwarming anecdote rather than the scientific evidence. But I still feel it important that pet owners are aware of the scientific and skeptical perspective so that they have the opportunity to consider the evidence before making healthcare choices for their pets.
Therefore, I usually agree to be interviewed for these articles even if I often end up being portrayed negatively or being the “token skeptic” in a piece generally very positive to a therapy I am critical of. On the other hand, sometimes I find I am asked to provide a negative perspective on a therapy I actually have a positive view of, since people sometimes mistake skepticism for a globally negative attitude towards new or unfamiliar ideas, rather than simply as an attitude of requiring substantive evidence before drawing conclusions about a claim.
I have kept track of many of the articles for which I have been interviewed since one of my interests is the portrayal of science and alternative medicine in the media. I have posted this list here, since the articles may be of interest to some readers. However, I must emphasize that just because an article is listed here or I have been quoted, I do not necessarily agree with the claims or perspective of that article. Even my own quotes, I have found, can sometimes be arranged so as to create a misleading impression of my views on the subject being discussed. Therefore, I do not necessarily endorse the claims or arguments presented in these articles, even if they are supported by selective citation of my comments. Certainly, there are many points I do agree with in some of these, but I only take credit or blame for my own words in their full context.
Vet says pet pot could fix one of most common owner complaints
By Robin Roberts
Daily Brew, 2015
If Your Veterinarian Offers Acupuncture, Find a Different Vet: Sticking needles in your dog won’t make it feel better.
By Brian Palmer
Slate, 2014
Acupuncture for Your Dog
By Mary Helen Miller
WUTC radio story, 2014
Pet Lovers Beware: When The Drugs Don’t Work
By Peter Aldhous
Medium, 2014
Evidence, communication key to evaluating veterinarian
By Brennen McKenzie
SF Gate.com, 2014
Spay & Neuter Quandary: Weighing the new options.
By Martha Connors
Bark Magazine, 2014
Homeopathy Debate Heats up as AVMA Policy Review Nears
By Heather Biele
DVM360 Magazine, 2014
Judging Merits of Homeopathy not an AVMA Objective
By Jennifer Fiala
VIN News Service, 2014
Raw Diets for Pets: Weighing the Pros & Cons
By Sandra Murphy
Natural Awakenings, 2013
Pet Psychics: Pet Mind Readers?
By Rutaksha Rawat
Creature Companion, 2013
Nutrition Plus A wide variety of supplements are popular among pet owners.
By Kerri Chladnicek
Veterinary Practice News, 2013
Stem Cell Therapy for Dogs: Unleashing Hope, Angst
By Tom Kisken
Ventura County Star, 2013
How much rawhide is too much for dogs?
By Brennen McKenzie
SF Gate.com, 2012
The Promise of Probiotics
By Elizabeth Devitt
Pet Age, 2012
Let the Evidence Show
By Mark Thill
Veterinary Advantage, 2012
Pet pointers: Meow-choo, Meow-choo! Sneezing in Cats, Diet and Kidney Disease
By Brennen McKenzie
San Jose Mercury News, 2011
How to Help Elderly Dogs with Degenerative Conditions
By Brennen McKenzie
San Jose Mercury News, 2011
Don’t Pamper Pets with Halloween Candy
By Brennen McKenzie
San Jose Mercury News, 2010
In 2010, I published a narrative review of the literature evaluating the risks and benefits of neutering in dogs and cats. Much additional research has been completed and published since then, and I have just complete an update of my review. The new evidence has resulted in a number of changes to my conclusions and recommendations, so while I will leave the link to my previous review active, this update supersedes the older version.
Evaluating the Benefits & Risks of Neutering Dogs and Cats: 2014 Update
I’ve written a couple of times about Dr. Andrew Jones, a vet from Canada who makes his living selling alternative therapies and “veterinary secrets” online. Dr. Jones was once a practicing veterinarian, not just an online huckster and snake oil salesman. However, despite repeated warnings and fines from the regulatory authorities, he refused to stop making unfounded and illegal claims, drumming up business by claiming the rest of the veterinary profession were incompetent and greedy and suppressing “The Truth” about alternative therapies. Rather than abide by reasonable standards of respectful, professional behavior, he choose to surrender his license to practice medicine.
The ruling against him by the regulatory board sums up how Dr. Jones operated, and how he continues to conduct himself:
This Panel was dismayed, disheartened and discouraged by the extent to which the Respondent, Dr Andrew Jones, expresses a disparaging attitude towards his colleagues and his profession throughout his writings.
The Panel considered Dr Jones’ marketing material a serious example of his unprofessional behaviour in that his marketing material has an all pervading, persistent theme of denigrating other members of his profession in order to draw attention to himself. In his self-laudatory statements, Dr Jones’ constant harangues serve to throw the veterinary profession into disrepute.
Giving up his license undoubtedly freed him to fully indulge his primary marketing strategy, sowing fear and mistrust of science-based medicine in order to sell questionable alternatives and quackery. What is more, it allows him to portray himself as an altruistic “outsider” speaking truth to power and caring only for the welfare of animals and their human companions. He manages to put quite a self-serving spin on his legal troubles, casting himself as a martyr oppressed by malign forces out to crush alternative medicine.
Clearly the College of Veterinarians wants me to stop publishing on the Internet, especially alternative dog and cat health information…The profession loses as the College of Veterinarians has directed disproportionate resources towards prosecuting me, and further muzzled any current practicing Veterinarians who are inclined to speak out. Who wins? A small group of conservative Veterinarians who want to keep practicing Veterinary medicine conventionally, with no room for dissenting opinions.
Ultimately, someone has to make a stand, and I am frankly tired of The College of Veterinarians being the big Bully on the playground that no one is willing to stand up to.
As silly and disingenuous as this image is, it certainly resonates with his supporters, who are vehement, even hysterical in their response to any criticism of Dr. Jones. In a follow-up to my post about Dr. Jones, I shared some of the bizarre and childish comments from his defenders, including these gems:
This idiot must not have much to do, or the jam to say who he is. That makes him a weak minded, useless piece of dog poop!
What a spineless excuse for a human being.
a highly volatile dictatorial site run by a wannabe megalomaniac. A truly disturbed person with a anger management issue venting via their little site to their own personal herd of sycophants. I would dismiss them like a fly on your arm. Just troubled souls with no purpose.
Just another stooge for corporate interests such as big pharma
You are a lying scumbag…… eat dog shit and die !!!! you evil money monger !!!!
Certainly, Dr. Jones sets the tone on his site with his own persistent slurs on the veterinary profession. Posts like “Why I am ashamed to be a vet: a shocking expose of the profession” and “Bad Vets,” and his book, “Veterinary Secrets: How conventional veterinary medicine may be harming your pet and what you can do about it” illustrate his attack-dog marketing style, and the enormous ego it takes to decide that nearly the entire veterinary profession is ignorant or venal and only you and a select few know The Truth.
And for someone whose business model is founded on denigrating other veterinarians, Dr. Jones seems to have a fairly thin skin. His response to my first post about him ignored all the issues and simply whined about my supposed anonymity. And though that little kerfuffle was three years ago, apparently Dr. Jones still harbors some resentment.
He recently wrote a post entitled Scientific Evidence for Homeopathy. This is ludicrously misnamed since he actually avoids scientific evidence almost entirely. I have reviewed the research on homeopathy in detail, documenting the case against it, responding in careful detail to the poor evidence presented to defend it. Dr. Jones ignores all of this, instead choosing to mention one medical institution that has bought into homeopathy, cite one research study (which has been critically reviewed and shown not to be reliable), and finally fall back on the refuge of quacks through the ages—personal anecdotes.
I noticed this post when it came out, mostly because Dr. Jones used a screenshot of a post from this blog to illustrate the science-based view of homeopathy. In the piece, Dr. Jones disparagingly refers to the majority of scientists and the medical profession, including myself, who acknowledge the failure of homeopathy in scientific tests as “so called torch bearers of ‘evidence based whatever’” and suggests that rather than warn the public that homeopathy is quackery we “sip on some soothing chamomile tea.”
Despite the reference to my blog, I didn’t see any reason to respond to the post since nothing of substance was said, and I’ve answered these sort of vacuous clichés many times. However, a reader subsequently pointed out a little detail I’d missed which I thought nicely illustrated the reality behind Dr. Jones’ carefully crafted image. Though he casts himself as altruistic and noble, standing up against the bullies, cynics, and hateful stooges of industry, occasionally little windows open up in this saintly façade. In this case, Dr. Jones couldn’t help but express his real feelings when he captured and named the screenshot of my blog:
http://www.theinternetpetvet.com/wp-content/……asshole.png
Though it’s been three years since I wrote about Dr. Jones, and despite his own “persistent theme of denigrating other members of his profession in order to draw attention to himself…in his self-laudatory statements,” Dr. Jones apparently still harbors some pretty personal anger about the criticisms of him I have made, and he expresses this in as silly and unprofessional a manner as the supporters I quoted above.
Dr Jones likes to characterize those who criticize his nonsense or his method of promoting it as angry, threatened, or somehow acting on malign personal motives. In the past, Dr. Jones characterized my criticism as expressing “a strong dislike” of him. This is merely a projection of his own narcissism. I have no personal feelings about Dr. Jones, and his claims and actions do not directly affect me in any way, neither personally nor professionally. I believe he is either deluded or dishonest in many of his claims, such as the claim that homeopathy has any therapeutic value. And I believe pet owners and our animal companions would be better off if he were not spreading misinformation on the internet. But he has the right to spread it, just as I have the right to identify it as the nonsense it is.
If Dr. Jones chooses to claim publically that science-based veterinary medicine is useless or harmful and that other veterinarians are misguided or venal, and he does so in order to sell his own products, he ought to expect some criticism. If he really believes in what he is peddling, he would be far more successful in defusing this criticism by backing up his claims with real evidence, rather than making silly, snide comments about “evidence-based whatever” and sneaking grade-school insults into his posts.
One of the most bizarre manifestations of pseudoscientific and anti-scientific thinking, particularly popular among homeopaths, is the insistence that the most effective preventative healthcare intervention in history, vaccination, is actually a dangerous and destructive poison foisted on the unsuspecting public by ignorant or evil doctors. In the human health arena, this is most dramatically seen in the persistent belief that vaccines cause autism, despite overwhelming evidence this is not true, and in the resurgence of preventable diseases in areas where misguided parents choose to deny effective immunization to their children.
Veterinarians and pet owners, sadly, are no more resistant to nonsense and unscientific fear mongering about vaccines. I have written before about misguided vets who encourage clients to expose their animal companions to potentially deadly infectious diseases rather than make appropriate use of safe and effective vaccines. No one denies that vaccines can have undesirable effects. Most rare and minor, and some are rare but very serious. However, the overwhelming majority of the claims made by anti-vaccine activists about vaccine safety are pure fantasy unsupported by any real scientific evidence. A recent example, pointed out to me by a reader, illustrates the shameless use of distortion, misuse of irrelevant references to real science, and pure invention and lies to generate irrational fear of vaccines.
An article from the usually unreliable source Dogs Naturally Magazine, has been making the rounds on Facebook with claims that rabies vaccination causes violent behavior in dogs. I am hesitant to discuss this claim simply because it is like discussing the intellectual merits of creationism or alien abduction—the very act of refuting it makes it seem like an idea that is sane enough to deserve a response. Unfortunately, such nonsense, however ludicrous, can still mislead pet owners into making dangerous choices for their pets, so I will briefly point out why this article deserves to be dismissed out of hand.
Emotionally manipulative use of anecdotes-
The article tells tragic stories of people injured by their dogs. As horrible as these experiences are, they have absolutely no bearing on the truth of the claim that rabies vaccine were responsible for the behavior. There are thousands of dog attacks worldwide every year and the overwhelming majority of them do not follow any kind of vaccination. To claim that the occurrence of vaccination before such an attack is evidence for a causal relationship is an elementary error in logic that is inexcusable in anyone with even a rudimentary scientific education. It is as ridiculous as believing that we cause it to rain by washing our car.
The purpose of these stories is not to prove anything, since they cannot, but simply to manipulate people into feeling fear.
Self-serving conspiracy theorizing-
The article acknowledges that the overwhelming majority of veterinarians, with extensive training and experience in veterinary medicine, reject the theory that rabies vaccination causes aggression. Instead of recognizing that this might be a reason to question the hypothesis, the article suggests that the few who believe in the idea are the only ones smart enough, brave enough, or otherwise capable of seeing a supposedly obvious relationship. The majority who reject it must be either unconscionably ignorant or deliberately ignoring the truth despite the danger to their patients and clients.
The sheer arrogance of this kind of thinking is stunning. Certainly, widespread belief in an idea is not incontrovertible evidence that idea is true. The majority is wrong about things all the time (which the folks at Dogs Naturally conveniently ignore when they are claiming we should accept alternative therapies because lots of people think they work). However, when almost all the experts in a scientific field agree and only a few practitioners of pseudoscientific nonsense like homeopathy think the idea is true, that is reason to at least ask the question, “What’s the evidence?”
There is no evidence-
Which brings us to the other ways in which the article tries to support its fantastic claim. The simple fact is that there is no scientific evidence to back up the claim, so the article cheats and tries to imply that other claims which are true somehow imply theirs is too. For example, lots of quotes from the Merk manual (a rather old-fashioned medical reference pretty universally ignored by real doctors and scientists) about encephalitis. This article, however, has nothing at all to do with rabies vaccination. It’s like saying that because diabetes exists it must be true that wearing blue causes diabetes.
The article also cites references (most 30-40 years old) to neurologic disease cause by distemper vaccines (NOT rabies vaccines). This is a rare and acute disease caused by insufficient weakening of the distemper virus used in the vaccine and has nothing to do with rabies vaccination (a killed viral vaccine) or with any of the other suggested causes for the mythological disease of rabies-vaccine induced aggression. The same is true for the citation of a forty-year old Italian journal article on vaccination and epilepsy and all of the other references to irrelevant scientific research that has nothing to do with the claims made in this article.
The article supports its claims with references to other disproven and ridiculous claims-
As already mentioned, the claim that vaccines cause autism is complete nonsense that has been thoroughly disproven, and the main research paper suggesting this relationship has been withdrawn for fraud and its author stripped of his medical license. Citing this idea and its supporters in defense of the claims made about rabies vaccines in this article is itself a strong reason to ignore those claims since their proponents clearly will believe anything no matter what the evidence.
The same is true for the claim that veterinary homeopaths have an explanation for the problem in the form of the “Rabies Miasm.” A miasm is a completely bogus idea invented in a time when people still believed demonic possession was real and bloodletting was a safe and effective treatment for disease. It has all the scientific legitimacy of astrology or, for that matter, the rest of the theoretical nonsense that underlies the practice of homeopathy, which I have discussed many times before. The symptoms listed as supposed signs of Rabies Miasm are a hodgepodge of things that, like any good horoscope, one can see as applicable to absolutely every patient with any disease to one extent or another.
In addition to referencing Andrew Wakefield and Richard Pitcairn, both classic quacks promoting pseudoscientific alternatives to real medicine, the article quotes Russell Blaylock, a former neurosurgeon who has become a full-time crusader against scientific medicine and in favor of a wide variety of ridiculous pseudoscientific ideas, and Harold Buttram, another rabid anti-vaccine activist. These are not “experts” or reliable sources but ideological crusaders opposed to the majority not only of scientists and doctors but the majority of the actual evidence concerning vaccine safety. Referencing them simply reinforces the extremist and anti-science nature of this article and its claims.
Now undoubtedly, people will make comments on this post like “How can you be sure rabies vaccine doesn’t cause aggression?” I am happy to admit the idea is not impossible. However, the decision whether or not to change a well-established medical practice that has had great benefits is not whether concerns about it are possible, but rather whether there is any reason to believe they are justified. In this case, there is not.
Rabies is a deadly disease which has caused enormous suffering and death for humans and animals alike for thousands of years. Rabies vaccination has virtually eliminated this problem for dogs in developed countries, and for the people those dogs would kill if they were afflicted with rabies. And in the decades over which this has been accomplished, there has been no reliable scientific evidence to suggest the vaccine causes the problems claimed in this article. As I have shown, these claims are made by ideological extremists who support many conclusively disproven ideas, and they have offered no evidence to back up their claims, only emotionally manipulative anecdotes, irrelevant and misleading references to unrelated science, and the opinions of unreliable believers in pseudoscience.
This article is not a reason to abandon rabies vaccination or expose your pet and your family to the risk of this terrible disease. Please do not be frightened or misled by these false arguments and scare tactics. Rabies vaccines are not perfect, but they are incredibly safe and very effective, and they save lives, both human and canine. Any change in our use of these vaccines should be based on sound science, not hysteria and pseudoscience.
I’ve written previously about the evidence concerning hyperbaric oxygen therapy (HBOT). There are a few specific conditions for which there is reasonable evidence HBOT is a useful therapy. Unfortunately, it is becoming something of a fad treatment in veterinary medicine, and there are many claims and recommendations for HBOT that are not supported by real evidence. A new series of studies in humans from the Department of Defense has provided some additional useful evidence regarding this treatment.
Reported in the LA Times, these studies specifically examined HBOT as a therapy for symptoms of concussion in service members. The results so far consistently show no difference between HBOT and placebo, suggesting no real therapeutic benefit for the treatment. In one study, 72 patients were randomly assigned to HBOT or sham HBOT. Both groups showed a 30% improvement in symptoms reported on a patient questionnaire, with no difference between the real and placebo treatment. This is in agreement with two previous randomized clinical trials of HBOT of concussive symptoms, neither of which reported any benefit greater than placebo. The fourth, largest and most rigorous trial is still in progress.
What is especially interesting about these results is that both HBOT and placebo groups showed significantly more improvement than patients given standard care. This reflects the very similar results of acupuncture trials and studies of many other therapies which are no better than their sham placebo comparators but which appear to provide a benefit when compared to nothing at all or to minimal standard care.
Does this mean that placebo effects represent real healing? Absolutely not! Many studies have shown that placebo effects only change the perception of one’s symptoms and certain autonomic values (like blood pressure and heart rate) that are strongly influenced by psychological factors, not the objective measurements of one’s illness. What the results mean is that the ritual of care, particularly the more elaborate and involved the ritual is, improves how people feel even when the therapy does not actually change their physical condition.
It is useful to remind ourselves of this phenomenon for two reasons. First, it reinforces that we cannot believe the positive results seen in studies that do not have an effective sham or placebo treatment, because they cannot distinguish real improvement from the psychological effects of therapeutic rituals. Secondly, it gives human healthcare workers the opportunity to take advantage of such effects to improve patients’ experience of care. This should not be done by providing ineffective or fake therapies, of course. But there are many ways to generate a comforting therapeutic ritual while still providing scientific, evidence-based care.
In veterinary medicine, sadly, it is likely such rituals treat animal owners much more than our patients themselves (the caregiver placebo effect). Though this may have some value anyway, it raises the significant risk that we will convince ourselves and our clients we are helping their pets when we actually are not. Therefore, we in veterinary medicine have to hold our selves to the strictest standard of evidence we can to avoid fooling ourselves and our clients at the expense of our patients.
Homeopaths, naturally, refuse to recognize that their entire profession is nothing more than the selling of placebos. The evidence against any true benefit for homeopathic therapy, beyond the psychological benefits of the therapeutic interaction, is overwhelming. Reviews by scientists and government agencies consistently find no reason to believe homeopathy is a real, effective medical practice. Homeopaths themselves have waded through 150 years of research and found virtually nothing better than anecdotes to suggest homeopathy is worthwhile. Yet homeopaths continue to have faith, since after all homeopathy is more of a faith-based belief system than a science.
This unshakeable faith leads homeopaths to advocate some pretty frightening and ridiculous uses of their treatments. Homeopaths have advocated their magic water for treatment of everything from cancer to ebola. This would be funny if it didn’t subject patients to serious danger, primarily from homeopaths recommending their remedies in place of real medicine. However, even most homeopathy advocates tend to acknowledge that science-based medicine is more appropriate than homeopathy as the primary treatment for victims of trauma. The idea of homeopathy as an emergency therapy is so ludicrous as to have been lampooned by popular British comedians Mitchel and Webb:
It is true that one of the more extreme veterinary homeopaths I have written about, Dr. Will Falconer, has claimed his nonsense can help people avoid taking their pets to a veterinarian for emergency treatment even in the face of life-threatening acute illness, but I had hoped he was an isolated case that might be ignored, if not publically disavowed, by other veterinarians promoting alternative therapies. However, sadly I have found yet another veterinarian who shares the delusion that it is ethical or appropriate to recommend homeopathy as a therapy for shock in pets.
Blogger “Dr. Jessie” has a recent post referencing a case report in the Journal of the American Holistic Veterinary Medical Association entitled, apparently without irony, Homeopathic Remedies for Canine Trauma. In the article, she describes the case of a dog who attacked a passing car and suffered broken teeth and possibly neck and head trauma. The article then describes the use of two homeopathic remedies for this patient, and strongly implies that they alleviated the dog’s pain. Hopefully, real pain medication and other medical treatments were provided, but none are mentioned in the post, again implying that homeopathy alone would be sufficient treatment for a patient like this.
Since the AHVMA does not routinely make its journal available to non-members, and it is not referenced in most databases of real scientific journals, I have not yet been able to find a copy of the original case report. Again, I hope that the homeopathic remedies were used in addition to real medical treatment and, as is so often the case, simply given credit for improvement more likely due to other treatments. Unfortunately, I have seen other so-called holistic veterinarians also claim miraculous results from the use of homeopathic remedies in animals hit by cars or suffering other forms of trauma, though most then use conventional therapies as well. However, the very idea that a practicing veterinarian would suggest homeopathy as an adequate or appropriate therapy for shock or trauma demonstrates a frightening disconnect from reality that undoubtedly puts patients at risk of inappropriate treatment.
Prompted by Dr. Hall’s recent assessment of the state of science-based medicine in Australia, I thought it was time to offer a “state of the profession” update on how science-based and evidence-based medicine in the veterinary field are doing in competition with opinion-based or faith-based medicine and outright woo. The situation resembles that in human medicine in many ways, of course, but the context is quite different, and that difference tends to put science-based medicine at a bit of a disadvantage.
The Context
The scale of the veterinary medical market is diminutive compared with that of human medicine. Perhaps the largest commercial player in veterinary pharmaceutical research, Zoetis (formerly a division of Pfizer) spent an estimated $400 million in 2013. By contrast, Pfizer itself has drastically cut its research budget for human medicines to a mere $6.5-7 billion for 2013. The difference in revenues is similar, and this provides less incentive for investment in the kind of research needed for truly science-based medicine.
The quality and quantity of research evidence in veterinary medicine is inevitably far lower than is commonly expected in human medicine, and consequently so are the standards of evidence clinicians and clients expect. Even with the best of intentions, we simply can’t expect to match the standards of our big-city cousin, human healthcare.
And due to the lesser societal value placed on animal health, except where it intersects with human health and the food supply, there is far less in the way of regulatory oversight of veterinarians. Most of the drugs we use, for example, are never licensed for the species or indication in which we use them. Off-label use based only sparse research or uncontrolled clinical experience is the standard.
Also, because animals are technically property, owners are free to do virtually anything they want to them. The application of almost any kind of quackery is completely legal under most circumstances. And even when there are rules about the claims and uses of a particular therapy, the understanding is that government will not enforce these unless there is a perceived direct impact on human health.
A recent example of this is the use of stem cell therapies in veterinary medicine. The FDA does not currently license any stem cell therapies for human use. The International Society for Stem Cell Research, which presumably consists of scientists convinced such therapies are very likely to prove safe and beneficial for at least some uses, still cautions people that the evidence for this is not yet available and that they should not seek out such therapies in countries where regulators do not prohibit them.
We have all heard about the extraordinary promise that stem cell research holds for the treatment of a wide range of diseases and conditions. However, there is a lot of work still needed to take this research and turn it into safe and effective treatments.
The International Society for Stem Cell Research (ISSCR) is very concerned that stem cell therapies are being sold around the world before they have been proven safe and effective.
Stem cell therapies are nearly all new and experimental. In these early stages, they may not work, and there may be downsides. Make sure you understand what to look out for before considering a stem cell therapy.
Remember, most medical discoveries are based on years of research performed at universities and companies. There is a long process that shows first in laboratory studies and then in clinical research that something is safe and will work. Like a new drug, stem cell therapies must be assessed and meet certain standards before receiving approval from national regulatory bodies to be used to treat people.
The evidence for the safety and efficacy of such therapies in veterinary patients is even weaker than that in humans, and yet stem cell therapies are widely marketed and in veterinary medicine. The FDA has jurisdiction over this practice, and the agency recently asserted its authority to require licensing of these products. However, even in the document claiming the right to regulate these treatments, the agency has indicated it is unlikely to do so when they do not clearly impact directly on human health or the food supply:
Although [autologous stem cell therapies] require [FDA approval], conditional approval or index listing to be legally marketed, FDA recognizes that these products pose a lower risk to human and animal safety than other categories of [stem cell therapy] when used in non-food producing animals and are, therefore, a lower enforcement priority.
The same understanding applies in most areas of veterinary medicine, so veterinarians are largely free to market any and all therapies without regulatory approval. While this may be necessary to ensure that therapies are available to veterinary patients in the absence of sufficient financial incentives to drive companies to seek licensing, it opens the door much more widely to woo than is generally the case in human medicine.
The Good News
The good news is that there are individuals and organizations in veterinary medicine committed to science and evidence-based practice. Efforts to promote this approach have grown dramatically in the last decade, and they are beginning to have an impact on at least the language, if not the underlying thoughts or actions, or practitioners. It is impossible to attend a veterinary continuing education conference without hearing titles like “An Evidence-Based Guide to Therapy X,” though the content is often less true to the principles and methods of EBM than such titles would suggest.
The organization I am most directly involved with is the Evidence-Based Veterinary Medicine Association (EBVMA). A small organization of about 75-100 people, promotes EBM at veterinary continuing education meetings, lobbies for incorporating EBM standards in research, publishing, clinical guidelines, and so on, and provides a small amount of funding (currently $1500/year) for research targeted at promoting evidence-based veterinary medicine.
The Centre for Evidence-based Medicine (CEVM) at the University of Nottingham is a funded academic center aimed at conducting and supporting research to facilitate more evidence-based veterinary practice. The center has begun producing some very useful resources, such as a database of veterinary systematic reviews, and a small but growing collection of critically appraised topics for veterinary practitioners.
Such resources may seem rudimentary to physicians accustomed to much more voluminous and accessible synthetic literature, but these are essential first steps in helping veterinarians get accustomed to relying on science more and personal experience less. A recent study, for example, found that the number of systematic reviews in the veterinary literature has increased exponentially in the last ten years. It is still only a tiny number compared to the more than 5,500 systematic reviews produced by the Cochrane Collaboration alone by 2013, but it is a necessary start.
Perhaps the most exciting recent development in support of more science-based veterinary medicine has been the involvement of the Royal College of Veterinary Surgeons (RCVS) charitable arm in organizing and funding evidence-based veterinary medicine. The RCVS Knowledge group has offered grants in support of EBVM research and activities and has organized an international EBVM conference this fall.
In the absence of substantial government funding, private resources support most veterinary research. Industry is the largest player, including pharmaceutical companies, pet food companies, and the like. This money is, as I’ve mentioned, a tiny fraction of the equivalent R&D investments in human medicine, and it likely comes with the same risks of bias and other problems identified in human healthcare (though there is little research on this subject in veterinary medicine).
Private non-profit organizations and academic institutions make up most of the rest of support for the science behind veterinary medicine. As an example, the Morris Animal Foundation is the largest non-profit supporter of veterinary research, offering several million dollars annual in grant funding. Morris is currently funding the first longitudinal lifetime health study in dogs.
As in human medicine, most vets are probably shruggies; they practice mostly conventional medicine, but they think of themselves as “open-minded” and don’t see a problem with the integration of alternative therapies into routine practice. There is a bit of a cultural taboo, at least in the U.S., of criticizing the practices of other vets, so challenges to alternative practices often draw hostile responses not only from CAVM advocates but other veterinarians who don’t themselves offer alternative therapies. The notion that civil, substantive critique is essential to progress and the scientific method is not widely appreciated.
Science, and an evidence-based approach to practice, are only rarely specifically endorsed by veterinary institutions. Even fewer openly reject alternative therapies. The American Veterinary Medical Association, for example, used to have a policy on CAVM that stated:
The theoretical bases and techniques of CAVM may diverge from veterinary medicine routinely taught in North American veterinary medical schools or may differ from current scientific knowledge, or both.
The AVMA believes that all veterinary medicine, including CAVM, should be held to the same standards. Claims for safety and effectiveness ultimately should be proven by the scientific method… Practices and philosophies that are ineffective or unsafe should be discarded…Recommendations for effective and safe care should be based on available scientific knowledge and the medical judgment of the veterinarian.
Under pressure from CAVM advocacy groups, that has since been amended to remove any reference to science:
The AVMA believes that all aspects of veterinary medicine should be held to the same standards, including complementary, alternative and integrative veterinary medicine, non-traditional or other novel approaches.
- The foremost objectives in veterinary medicine are the health and welfare of the patient.
- Diagnosis and treatment should be based on sound, accepted principles of veterinary medicine and the medical judgment of the veterinarian.
- Veterinarians should have the requisite knowledge and skills for every treatment modality they consider using.
- A valid veterinarian-client-patient relationship must exist1.
- Owner consent1 should be obtained prior to initiating treatment.
- Medical records should include outcomes of treatment.
- Veterinarians should be aware of and abide by local, state, and federal statutes.
In contrast, the Australian Veterinary Association (AVA) has a policy rejecting any support for ineffective therapies generally, and specifically identifying homeopathy and homotoxicology as examples of such therapies:
Australian Veterinary Association (AVA) resources will not be used to promote therapies that, in the Board’s opinion, are not compatible with current understanding of physiology and pathophysiology and have been demonstrated to be ineffective by the current accumulated body of knowledge.
That the Board agreed that the veterinary therapies of homeopathy and homotoxicology are considered ineffective therapies in accordance with the AVA promotion of ineffective therapies Board resolution.
An attempt to pass a similar resolution in the AVMA was defeated overwhelmingly. Only a few other major mainstream veterinary organizations have taken formal positions on science and alternative medicine:
European Board of Veterinary Specialties
The veterinary profession received the prerogative for diagnosis and treatment of animal diseases based on the assumption that veterinarians are guided by scientific methods. The EBVS therefore only recognises scientific, evidence-based veterinary medicine which complies with animal welfare legislation Specialists or Colleges who practise or support implausible treatment modalities with no proof of effectiveness run the risk of withdrawal of their specialist status. No credit points can be granted for education or training in these so-called supplementary, complementary and alternative treatment modalities.
British Veterinary Association
The BVA cannot endorse the use of homeopathic medicines, or indeed any medicine making therapeutic claims, which have no proven efficacy. As with any medicine, BVA believes that veterinary medicinal products must be evidence-based, with any medicinal claims made by a manufacturer supported.
Federation of Veterinarians in Europe
[veterinarians should] work only on the basis of scientifically proven and evidence-based methods and to stay away from non-evidence-based methods.
The American Association of Veterinary State Boards (AAVSB), which is responsible for certifying continuing education (CE) courses for veterinarians taken in support of continued state licensure through the Registry of Approved Continuing Education (RACE), explicitly requires that subjects approved for RACE continuing education credit be based on sound scientific evidence, and the teaching of ineffective or unsafe practices cannot be approved as continuing education for veterinarians:
CE offerings shall be designed to…refresh the participant in the standards for practice and the foundational, evidence-based material presented in accredited colleges or schools of veterinary medicine… CE programs that advocate unscientific modalities of diagnosis or therapy are not eligible for RACE approval.
Furthermore, those programs that promote treatments known to pose significant risks, dangers that outweigh benefits or unproven effectiveness are generally not considered approvable. All scientific information referred to, reported or used in RACE Program Applications in support or justification of an animal-care recommendation must conform to the medically accepted and scientifically supported standards of experimental design, data collection and analysis.
This means in practice RACE will not certify most CAVM education. The Academy of Veterinary Homeopathy (AVH) actually sued the AAVSB to try and force them to accredit homeopathy CE courses. When this failed, CAVM proponents created their own CE accreditation organization to rubber stamp their own CE offerings, which unfortunately many states are accepting as legitimate.
Overall, the majority of veterinary medicine offered is at least compatible in theory with science-based medicine, though often the level of evidence available to support it is less than would be acceptable in human medicine. Most veterinarians stay away from the most egregious quackery, such as homeopathy and “energy medicine.” However, there is also bad news.
The Bad News
Apart from the serious lack of adequate scientific evidence to support even most mainstream veterinary practices, questionable or outright quack practices are widespread and appear to be growing in acceptability and popularity. Some of this reflects similar trends in human healthcare. People often begin to inquire about dietary supplements, herbal remedies, acupuncture, and chiropractic, as well as even more dubious practices, for their pets after having employed them for themselves or heard encouraging anecdotes from friends and family. While there is not any formal research evaluating the popularity of CAVM treatments, subjectively they certainly appear to be infiltrative academia and general practices at a frightening pace.
A large part of the credit/blame for this likely belongs to CAVM advocates, who are far better organized and funded, and far more aggressive than proponents of EBVM. The American Holistic Veterinary Medical Association (AHVMA) and its associated fundraising arm the American Holistic Veterinary Medical Foundation (AHVMF) have proven very successful at promoting CAVM and paying lip service to science and EBVM while clearly being interested only in promoting what they already believe without, or despite the scientific evidence. They promote the most ridiculous quackery at their CE meeting, like “Earth Acupuncture” to heal the planet, dowsing, and of course homeopathy, Traditional Chinese Veterinary Medicine, Reiki, and all the others. Yet they have managed to raise over $1 million in the last year to promote “research” and teaching of alternative veterinary therapies. By the standards of veterinary medicine, this is not small change!
Much of this money has been given to veterinary colleges in the form of grants to support teaching and research activities by dedicated CAVM proponents. The University of Tennessee, University of Florida, and University of Louisiana veterinary schools have received large grants and have become the leaders in veterinary quackademic medicine as a result. The comments of the leaders of the AHVMA and AHVMF make it clear this money is intended not for any kind of rigorous research evaluation of plausible CAVM practices, but simply to promote these and give them a patina of scientific legitimacy.
The AHVMA and AHVMF also organize student alternative medicine clubs at veterinary colleges and offer scholarships and other support for students wishing to study CAVM methods. The influence of this on what will be considered mainstream, legitimate medical practice in the future is potentially significant, and quite disturbing.
Apart from their fundraising success, these two organizations have been able to infiltrate and influence mainstream veterinary organizations. Along with the American Academy of Acupuncture, the AHVMA has been admitted to the governing body of the American Veterinary Medical Association. Perhaps not coincidentally, this organization effectively lobbied to kill the resolution in the AVMA House of Delegates to declare homeopathy an ineffective therapy. The AVMA statement on CAVM was also amended to remove any talk of science or scientific evidence at about the same time the AHVMA was admitted.
There are, of course, many other CAVM organizations also proselytizing and marketing their particular brand of alternative medicine. In addition to the organizations of homeopaths and acupuncturists, there are national and international academies and associations for veterinary chiropractic, traditional Chinese medicine, naturopathy, herbal medicine, pet psychics (sorry, “animal communicators”), and pretty much any other variety of alternative medicine you can imagine. And all of them offer certifications which, though not recognized by the official AAVSB, are indistinguishable from real, meaningful credentials to pet owners and most regular veterinarians. And all of these groups raise money, lobby, and otherwise promote their own brands of woo and most of the others at a volume that cannot be matched by advocates of EBVM and science-based medicine.
The internet is, of course, the Wild West for quack therapies. Claims are made for miracle treatments that are not only unsupported or unquestionably ridiculous but blatantly illegal. The FDA, FTC, and other relevant agencies almost never take any action, so it is very much a buyer-beware marketplace. The vast majority of the health information available to animal owners on the internet is marketing from someone with a product or practice to sell. I play whack-a-mole here as best I can with the most egregious misinformation, and a few others do the same, notably fellow SBM contributor David Ramey. But this is a mere drop in the CAVM propaganda ocean.
Where Do We Go From Here?
It is difficult to see the situation in veterinary medicine with respect to quackery improving any time soon. The resources, passion and momentum, and political environment all appear to favor the greater infiltration of alternative therapies into the mainstream of veterinary practice. The development of evidence to validate or invalidate the plausible among CAVM treatments is glacial. And the culture of veterinary medicine favors extreme individual autonomy and discourages open criticism and debate on the subject.
Professional institutions, such as the AVMA and specialty boards, are reluctant to criticize or discourage any practice that veterinarians can legally sell or to take any position on what constitutes scientifically legitimate medicine. And academic, research, and teaching institutions appear to be opening their doors to CAVM, with the hinges greased by contributions from the CAVM lobby. This raises the specter of the next generation of veterinarians being taught that homeopathy, energy medicine, and similar nonsense is legitimate, respectable, even “evidence-based” veterinary medicine.
Fortunately, there are organizations and individuals who see the problem, the danger the philosophy and practices of alternative medicine represent to our patients and our profession, and who are making an effort to stem the tide. SBM has had significant impact on the discussion or CAM in human medicine, and to a lesser extent those of us advocating for science-based medicine in the veterinary domain are attempting to do the same in our field.
At a minimum, continuing to challenge the claims of CAVM proponents mars their efforts to make their practices seem uncontroversial or ordinary and legitimate. Our efforts to highlight the facts may save at least some animal owners from being misled or buying into unproven or quack therapies. And perhaps we may even influence the next generation of vets ourselves, and sustain the skepticism needed to resist CAVM narratives.
Though the current state of science-based veterinary medicine is a bit shaky, there is hope. I encourage anyone interested in defending animals and animal owners from CAVM to get involved in one of the organizations I mentioned that are defending evidence-based veterinary medicine. Make it clear to your clients and colleagues, if you are a veterinarian or veterinary technician, or to your vet if you are an animal owner, that that science-based and evidence-based medicine are the right approaches to animal care, and that CAVM is not a safe, effective, or ethical alternative. Ask for evidence whenever a claim is made, and demand more than personal experience and testimonials.
And if you can, contribute not only your time and energy but financial support. Donations to non-profit groups supporting real research, like the Morris Animal Foundation, or promoting evidence-based medicine, can help balance the resources currently pouring into veterinary medicine in support of CAVM. And your choices of where you spend your money as an animal owner can make a difference too. Some vets offer CAVM because they believe in it. Plenty of others offer it becomes it sells! Make sure your vet knows that you want to pay for science-based care, not untested and implausible products and services or outright quackery.