Combating disinformation, and time to stop spinal injections for chronic pain
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Welcome to the Medicine and Science podcast from the BMJ. I'm Cameron Abassi, Editor-in-Chief.

There's a lot happening in the world and it's hard to keep up with the changes in the US but one thing is certain, disinformation is rife and we need to tackle it. I think that we need to go after these people. I think public health institutions need to be having a surveillance function for disinformation in the same way that they would have for outbreaks of infectious disease. Next, why spinal injections may not be the answer to back pain.

a strong recommendation against, as opposed to saying there's no evidence to support. And I think, you know, I'm 100% behind. There's no evidence to support. Repeatedly, there's no evidence to support. Five years ago, the BMJ published a landmark racism in medicine special issue. We'll hear about what progress has been made since then.

From the people that we spoke to, they felt that underreporting is definitely still a big issue. I think particularly in terms of incidents that happen when students are on clinical placement. We're recording this on the back of Volodymyr Zelenskyy.

saying that Donald Trump is living in a disinformation space created by Russia. We're going to be exploring the role of misinformation and disinformation in health. We'll talk about the US as well. And what does this mean for medicine, a profession where we need both good and accurate information, but also the trust of the public. To discuss these very important issues and very topical issues,

I'm delighted that I've got with me today Heidi Larson and Martin McKee. Heidi, please introduce yourself. Well, hello. Nice to see you both. And I'm Heidi Larson. I'm a professor of anthropology and risk and decision science at the London School of Hygiene and Tropical Medicine. Thank you, Martin.

I'm Martin McKee and I'm also at the London School of Hygiene and Tropical Medicine where I'm the Professor of European Public Health. Okay, so we're taking over the London School of Hygiene and Tropical Medicine today but purely on merit. Let's assure everybody of that. So we want to talk about misinformation and disinformation in the context of health and what's happening in the US. I think we better first start by defining what we mean by those terms. Heidi, would you like to have a go?

Sure. I mean, misinformation, both of them are inaccurate information, generally. But misinformation, people are sharing because they think it's plausible, not because they actually think it's real. And disinformation is purposely perpetrated information with

with not good motives. Okay. Martin? Yeah, absolutely. The key point is that disinformation is being deliberately spread for other purposes and maybe we should say what those purposes are. So we looked at this some years ago

One is simply clickbait because if you can get people to click on things on the internet, you can monetise the activity. Some of it is as a means to spread malware. Some of it is because people are deliberately pursuing an agenda which might be anti-vax or something like that. And some of it, quite a bit of it in the past has been linked to the Russian Federation

And that has been to undermine trust in Western democracies. OK. And you mentioned vaccination. And of course, we've been following events in the US. The confirmation of Robert F. Kennedy Jr., there was several points at which misinformation and what he'd said about vaccines occurred.

was discussed and was mentioned as a point of debate. Why do you think vaccines have become a particular focus for misinformation, disinformation? Heidi?

Well, the whole landscape of mis- and disinformation has expanded dramatically, thanks a lot to the ability to spread it more rapidly. But I think with vaccines, if you go back to the original reasons that people didn't want it, it was against God's will, it's not natural. But also, the thing that triggered the very early vaccine movement

in the UK were some of the same reasons now. And that was the day they put a compulsory legislation on the smallpox vaccine. That's what triggered it off. It wasn't an anti-vaccine league. It was an anti-compulsory vaccine league. And we have some of the same sentiments now. There's a whole bucket list

Other reasons, I think that's also the sheer number of vaccines. That's one thing that makes parents quite anxious. And there's a broader environment of publics having access to information. And that's also bred a lot of questioning. I know you believe that there are responses to disinformation or there are particular approaches you might adopt. Where do you start with this?

So this is very much Heidi's area, but issues like pre-bunking, you do not start off with the lie. You start off with the truth. Then you go to the lie and then you make the case against it. So I think how we frame things, I think as scientists, we're terribly bad at communication.

As you know, this is something I've felt very strongly about for a long time. And we think we've got some fantastic finding, which is actually pretty obscure. And we emphasise that because it shows that we're so clever.

not thinking through what the consequences of bigging it up really will be. I think that we need to go after these people. I think public health institutions need to be having a surveillance function for disinformation in the same way that they would have for outbreaks of infectious disease. And then they need to look at how they tackle it. Now, how they tackle it depends on where it's coming from and what the messaging might be.

But I think you need to be aware. You shouldn't be being caught by surprise by these things. - Martin's talking about and making when you say you've got to take these on and get these people, well, what happens when these people are the President of the United States and the head of the health services?

that's a whole different thing. It totally, totally emboldens anyone who had any inkling of a doubt. They say, well, you know, and the worst part about that is that it ripples across Africa, it ripples across Asia, it ripples across Latin America. For everyone

You know, it's a big problem and that's one that keeps me awake at night is there's a lot we can do but one of the things we do need to do and Martin already put his finger on it, we need a major investment and proactive engagement and we shouldn't count on the scientists to do it. We need communication partners, we need others to engage and surround this

And ran it in. Scientists and public health have been hugely hesitant and anxious and non-present in some

media. I mean, it was a major advance, technological advance, to get public health and health systems sending an appointment reminder. That was like, oh, we're there. You know, we sent appointment reminders, but not engaging where the public is. It's also not just simplifying the science, which is what

A lot of scientists tend to, but you're trying to take something complicated and make it simple, but that's not what people need or want. They want to say, well, why does it matter to me? We need to make it much more relevant and relevant.

And yeah, relatable. What you mentioned that you talked about very senior politicians being kind of agents of misinformation, disinformation. And of course, what's happened on top of that is that we've got Elon Musk and X and we've got, you know, what's happened with content moderation and fact checking on Facebook and

that's going to enable and accelerate the spread of misinformation and disinformation. It is doing already. From where I'm looking from, there does need to be better regulation of social media. Would you agree with that, Heidi?

Well, yes, in principle, but the reality is we're dealing with a situation where it's not. I mean, it is in some places more than others. And, you know, right now I can say I think it's important, but we need to deal with the reality that it's not. And I think that when they say we're leaving it to the communities to within these social networks,

to challenge each other, well then we better do that. Yeah, but we know that doesn't work because if you have community notes on X, nobody pays attention to them really. You've read the message or the tweet or the post. I don't necessarily only mean on X, but in general. Yeah.

I saw you write a piece, Martin, recently which talked about denialism. What is denialism and what can be done about it? So denialism is where there is a clearly established scientific consensus. Now, we always have to be careful with scientific consensus, but this is where there really is an overwhelming consensus. And there are people who are arguing against it. And there's a whole series of things they do, false analogies,

the so-called white coat scientists that the tobacco industry used to cast out on things. And what we argued, my colleague Pascal Diethelm from Geneva and myself in this paper, which is now about 15, 16 years old,

was that you really shouldn't get engaged in a scientific debate with people who are doing that because every time you win a point, they'll shift on to something else and you'll just be going round and round in circles and you'll have sort of established one point and then they'll say, well, what about that? But you just said that you need a whole bunch of scientists to counter these.

This misinformation. It depends on how it's done. If it's denialism and if you are dealing with denialism, then you don't waste your time. And I'm always minded in this with the example given by a very good friend and eminent professor of health economics from Canada, Bob Evans from Vancouver.

who said he was talking about dealing in health policy with what are called zombie ideas, ideas that are so mad, but every time you think you've killed them, they come back to life again. And he said, imagine you're a general practitioner in your surgery. A patient comes in claiming to be the Emperor Napoleon. You do not engage in a discussion of cavalry tactics at the Battle of Austerlitz. So scientific denialism, when you identify it, when it meets that definition,

There is no point embarking in a rational scientific conversation with that person. So what do you do? I simply would ignore them or I would do work which shows that...

tries to expose their motivations if we know it. You know, often the, I mean, some people just have strange ideas and that's fine. There's nothing much you can do about that. But often denialism is related, like climate denialism, for example, some of the denialism around the effects of tobacco smoke and so on. That takes you into the literature and commercial determinants. And that's where we have to use all of the methods that are there, that are exposing, really basically telling the world, why is this happening?

I'm quoting Al Franken, the junior senator from former junior senator from Minnesota. Why is this lying liar lying to me? And you need to make that clear. Yeah. Heidi, do you think Martin's approach would work with Donald Trump?

Well, I've got another... I mean, on the denialism front, I mean, a classic example is President Mbeki in South Africa. Yeah. In the face of a lot of clear scientific evidence about the effectiveness of the antiretrovirals, he hooked on to an alternative scientist's view that created...

I mean it led to there was a character an assessment of how many lives were lost 350,000 people died who could have lived had he not been a denialist and there was a policy to to support antiretrovirals what are you doing something like this again when it's it's one thing if it's a you know a guy in the street or your neighbor or even you know your mayor but when it's the head of the country

It's a whole different, you need to appeal to something else. And I'm not sure exactly what it is. Sometimes you need to go down to local level and get local information.

engagement and work around it and figure out ways to... But, you know, some of it is, frankly, evangelical. That is the biggest challenge that I've seen is that RFK Jr. deeply, deeply, deeply believes. He's not trying to pull the wool over people's eyes because he thinks it's the right thing. And a lot of parents...

I remember hearing people years ago, I mean, things have changed. They're trying to kill their kids. Why aren't they giving vaccines? They want to hurt their kids. Like they don't want to hurt their kids. They all think they're doing the best thing for their kids. All they want is their child to be healthy and safe. So it's one thing we all have in common. And I think we need to find that place where you agree.

And I think if there's one place that we all agree is we don't want to harm children or whatever it is, and then figure out other ways around that to get the conversation. Okay. Thank you. Martin, final word with you.

I'd just like to pick up on this idea about scientists and doctors as communicators. You know, this goes back to the time of Chekhov, for example. You know, there are a lot of doctors who actually described how he used literature, used poetry, used...

Cookery books, for example. The people who do this sort of thing we should really celebrate and not criticize them for going out and engaging with the public but saying, you know, really well done. Yeah. Whose cookery book are you thinking of? Salia Mahmood Ahmed. And she's a young gastroenterology doctor.

who won MasterChef and has subsequently written books on foodology and so on which are first of all great recipes but also have in them all the science and the nutrition and so on so there are lots of people who have found unusual unexpected ways to communicate and they're great so you're saying it's about good communication good communication I think that's a that's a perfect note to end this on making it relevant that's

it's something that people can relate to and for me cookery books do just that thank you both very much despite the common use of spinal injections in pain clinics around the world new research and guidance in the bmj strongly recommends against their use

I'm Tom Nolan. I'm a clinical editor at the BMJ and a GP, and I'm joined by Jane Ballantyne. Jane, welcome. Thank you for joining me. Can you just tell us a little bit more about yourself? Yes. Well, thank you for inviting me. I'm Jane Ballantyne. I'm a professor of anesthesiology at the University of Washington, which is in Seattle. I've actually been in the pain field for 30 years. I'm a professor of anesthesiology at the University of Washington,

Now I'm more interested in the big picture of what we're doing in pain management. Okay, which I suppose is where this BMJ rapid recommendations guidance comes in. And you've written an editorial for the BMJ on this.

I just thought we could maybe start by, I'd love to hear more about your experience of what happens in the US with people who have chronic pain. In the UK, although spinal injections are not recommended by NICE, our major guideline, they still happen a lot, and particularly in private practice. What happens in the US?

Well, it's not dissimilar, actually. But in the private practice, I would say it's more out of control in the sense that private practice clinics, quite a lot of them only do interventions. In fact, there was a recent article in JAMA that was a critique, which pointed out that a lot of the private practice clinics in the US will use the interventions as a

a bone for getting anything else, particularly prescriptions. So, say you come here, we'll do injections and we'll give you prescriptions, but if you don't have an injection, you don't belong in this clinic. So, it's used as a way to get people into the private practice clinics.

Right. Oh, dear. Okay. And you wrote in your editorial that an estimated 9 million injections per year in the US, which equates to about $9 billion worth of care on spinal injections.

That's a lot of money. Yes. It would be very difficult to put a really accurate figure on it. That is based on how much the average cost is to the payers. But it gives some idea of how expensive it is to patients. Well, should we look at the guideline recommendations then? I don't know if you could give us just a brief overview of that and what you made of those recommendations and how they're likely to go down in this field.

Yeah, so what the investigators did was look broadly at the common injections that are offered for the treatment of chronic back pain. And it's looking at the common injections and it's looking for evidence to support the common injections. And it takes a very wide net at the studies that are available.

and does it with a panel of experts and patients who have very little conflict of interest or no conflict of interest, which is what I think makes it stand out because a lot of the studies that have been, or the systematic reviews that have been published in the past, have either focused on only one condition or one treatment, but also

with a lot of conflict of interest. And I think that's why there's been this mixed picture. Some of them show benefit and others don't show any benefit. But the bottom line is that they can't find evidence to support it. And in their guideline, they follow that up with a strong recommendation against. And

I think that's very strong, a strong recommendation against, as opposed to saying there's no evidence to support. And I think I'm 100% behind, there's no evidence to support. Repeatedly, there's no evidence to support. That's right. I mean, that did cause some discussion, didn't it? Well, there is discussion of that in the guideline.

about how you would make a strong recommendation against and that needs to include some burden or potential harms of the intervention, which I think they felt were significant enough to warrant that recommendation. Yes. I mean, frankly...

They're pretty safe, the injections, but there is a risk somewhere there. It's something like 1 in 100,000. It's a very, very low risk of catastrophic outcomes like infections or spinal cord injury that can cause something as bad as paraplegia. But they're pretty safe generally, so they're not so unsafe that you would say you just shouldn't do this because it's not safe. Mm-hmm.

I mean, you're balancing that against the evidence that it doesn't really do much. And so, therefore, you can see that these recommendations may be controversial or take some people by surprise? Well, I think that they will be controversial because...

You know, as I actually said in the editorial, it's not just physicians that want to do it, it's patients that want it. If you do have chronic back pain, that's miserable. It's very hard to live with it. And just the idea of an injection that could make you better

fairly quickly as opposed to the treatments that, you know, I would say ultimately work much better and much harder for patients because they include things like lifestyle changes and exercise and thinking differently about pain. And it can take years to get better that way. So you can see why it's very appealing to a patient to that.

to go and have an injection that will make them better. So I think that demand will probably always be there. The question is whether you should pay for it, whether the healthcare system should pay for it. This actually makes me think of a couple of patients I've seen recently who've been really struggling with chronic low back pain and saying,

Really, I'm just trying to hang on until I can have my injection. And actually, I feel bad that I didn't really use that cue as an opportunity to try and shift away from focusing on the intervention. What would you suggest to someone in my position there to try and help these patients who are really struggling? Yes, well, I think it's one of the most difficult challenges ever.

we face as physicians, and we're not very well trained to do it, but I think we are beginning to

think more about how to prevent this focus on, you know, I go to the doctor and the doctor needs to give me something so that, you know, and that's going to make me better. And shift more into, you know, the sense of building a partnership and that it's not going to be something that you can achieve overnight. You have to gradually get away from the sense that you can fix everything, including the

a condition that's gone on for months with an injection. You know, it's education. I mean, one thing that's really big in America is this idea of what's called neuroscience education. And what neuroscience education, and it's really compelling and really successful, is to teach patients what's happening in the brain, basically, as they process pain. Because, you know, it's the pain processing.

A lot of people don't understand this, that nociception isn't pain. The signal that comes into the brain isn't pain at all until it's actively processed by the brain. And that piece is more amenable to treatment than whatever's going on in the periphery. So having that understanding. So it seems like it's

It really is the doctors and clinicians who need to change to improve care, as well as at the system level to make sure those incentives are aligned with the things that are going to really help our patients. Yes. I mean, you know, I think for physicians...

I'm sorry to say this, but follow the money. You know, the money is a huge incentive. The incentive is not just on an individual basis. It's the hospitals and the hospital systems and, you know, all the payers who drive it towards what?

patients want and will pay for and what the insurance and Medicare will pay for. I mean, Medicare is far less evidence-based. It's not evidence-based at all, in fact, compared to NICE. It's more based on other factors like what people are willing to pay for and what patients demand. So it's up to people who are, it's up to the payers to take note of what the evidence is and

and pay accordingly, is my view. Anyway, I think the money is a big issue. Five years ago, a BMJ investigation found that medical students were being let down by poor monitoring and responses to complaints of racism. Gareth Iacobucci, the BMJ's assistant news editor, repeated the exercise to see whether any progress has been made. Gareth, have we made progress? So at that stage, yes.

I think only around half of medical schools were even collecting data on complaints related to racism or racial harassment. So that figure now has risen, so it's around eight in ten now. The positive is that they now are collecting the data, but obviously I think collecting it is only part of the story isn't it? It's sort of what you do with that data and

And then there's also the question of how many complaints are being made which was a separate issue that we asked about as well. Okay, first of all, just to be clear, this is UK medical schools? That's right, yes. So yeah, it's 46 medical schools. I think we had data from 41 of them. All right, you had a reasonable response rate from them. When you say that another question is around how many complaints have been received,

What do you mean by that? So when we did this exercise in 2020, I think the number was that there'd only been 11 complaints recorded in the previous decade running up to 2020. So that's implausible, isn't it? There are only 11 instances. Phenomenally no number. Yeah.

In the five years since then, our data shows that there's been at least 138, which is still obviously modest, but it is higher than it was before, I guess. Sorry, but also if you start recording, obviously you're going to have more. Exactly, yeah. And I think so from the people that we spoke to, they felt that under-reporting is definitely still a big issue. I think particularly in terms of

incidents that happen when students are on clinical placements that was identified by several people as an area where there's still a lot of work to do yeah i think what you're describing is a situation that's also described in an editorial which is in the same issue that your investigation is published in fact we've had a we've published a theme issue again on racism in medicine and an editorial by anise ismail and sam everington um

captures it, I think, by saying that we've had an increase in acknowledgement of racism, but that doesn't mean that more has been done to address racism. And this is on a health system level. And it would seem to be that that's exactly what you're talking about here. Yes, yeah, completely. And I think one senior leader that I spoke to did make this point that actually tackling this issue

success can't be achieved just from medical schools taking action in isolation it needs sort of concerted coordinated action across the board so we're talking about employers your educational institutions society all it's

you know, it has to sort of be more joined up. I think that that was the message really. Yeah. Okay, Gareth, I think, you know, I think the situation is as described in that editorial I just mentioned by Aniz Ismail and Sam Everington in that racism is endemic and I think it's kind of intractable. I'm not sure we have good solutions.

But let's keep working and trying to improve the situation for people from, I think, minorities. Absolutely. Thanks very much, Gareth. Thanks, Cameron. Gareth's article, Racism in Medical Schools, Are Things Improving?, is now available and will be featuring more follow-up articles in that racism and medicine special issue over the next couple of months on bmj.com.

That's it for this episode of Medicine and Science. We'll be back in a fortnight with some more data on how the fight against racism in medicine is going. Until then, I'm Cameron Abassi. Thanks for listening.