Is Critical Care Medicine becoming a Cargo Cult of Vitamin C?
By Nicholas Mark, MD
During the 1940s, many Melanesian cultures were profoundly altered as the Second World War was waged in the Pacific around them. Western soldiers constructed airstrips out of the jungles and the natives witnessed vast wealth in the form of manufactured goods literally rain down from the skies on parachutes or carried by aircraft. This cargo - corned beef and other canned food, clothing, medicine, tents, jeeps, etc - was shared by the soldiers and was transformative for these indigenous cultures. After the war, these island bases were abandoned and the flow of cargo ceased. To fill the vacuum, "cargo cults" appeared, predicated on the belief that ritualistic acts such as the building of an runway would result in the return of material wealth, particularly the cargo dropped from airplanes. These cults established mock airstrips, complete with aircraft built from straw. Led by influential and charismatic “big men,” practitioners performed rituals including marching with wooden rifles with Western insignia painted on their bodies to resemble soldiers, speaking into radios made from coconuts and wood to approximate flight controllers, and lighting fires along the sides of runways attract the planes to return. In a 1974 Commencement Address at Caltech, Richard Feynman lamented what he called the appearance of “cargo cult science” wherein unscientific beliefs are cloaked in the scientific method. Similar to how the Pacific cargo cults created airports that were unable to produce Western airplanes, cargo cult scientists conducted flawed research superficially resembling the scientific method, but unable to produce useful or replicable results:
During the war they saw airplanes land with lots of good materials, and they want the same thing to happen now. So they've arranged to imitate things like runways, to put fires along the sides of the runways, to make a wooden hut for a man to sit in, with two wooden pieces on his head like headphones and bars of bamboo sticking out like antennas—he's the controller—and they wait for the airplanes to land. They're doing everything right. The form is perfect. It looks exactly the way it looked before. But it doesn't work. No airplanes land. So I call these things cargo cult science, because they follow all the apparent precepts and forms of scientific investigation, but they're missing something essential, because the planes don't land.”
Feynman cautioned that bad scientific practices - omission of a control group, lack of replication, poor use of statistics, and promotion of ones own results and suppression of contradictory findings - were undermining some disciplines, particularly in the social sciences. Analogous to the withdrawal of GIs from the Malaysian atolls, the decline in NIH funding coupled with the rising population of researchers has created conditions ripe for Critical Care Medicine to become a cargo cult. The disappointing public failure of therapies, for example the withdrawal of activated protein C or the demise of early goal directed therapy in sepsis, has created a void we we are eager fill by embracing new therapies. The proliferation of medicine on social media (Free Open Access Medicine or “FOAM") has created a rich discourse. Easy dissemination and discussion of medical ideas has undeniably salubrious effects, catalyzing the rapid adoption of new techniques, fostering collaboration between distant institutions, and emphasizing the importance of high quality medical education. FOAM is a two edged sword however, and its benefits are mitigated by some important flaws: 280 characters is too succinct for nuanced discourse. The loudest voices, not necessarily the most qualified, reach the most followers. Anecdote can be more compelling than reproducible evidence; YouTube videos are more entertaining than meta-analyses. FOAM celebrities, like the charismatic “big men" who led the pacific island cults, offer magical remedies including the “metabolic cure for sepsis”, which are published in scientific journals yet are fundamentally unscientific, lacking a control group. Bold pronouncements such as “all septic patients have scurvy” obfuscate the distinction between laboratory finding and clinical diagnosis. Subscribers of this cult succumb to post hoc ergo propter hoc thinking (also called the "normalization fallacy”) that correction of laboratory abnormalities will correct the underlying process. Single observations in cell culture are taken as unassailable mechanistic proof. Replication is derided as unnecessary (or even unethical) because it will delay implementation, eschewing a core scientific precept. The cargo cult of critical care is growing. To date, dozens of institutions have embraced the “metabolic cure” based upon evidence far flimsier than would be required for any “non-natural” medicine. Non-falsifiable theories ("this patient was saved by vitamin C”) are proffered as fact. Medicine benefits from unconventional people, but we must be cautious that eminence doesn’t supplant evidence. Like social media, the proliferation of ‘predatory journals’ facilitates these rituals by allowing anyone to publish anything. Like radios made of coconuts, these pseudo publications appeal to a similar kind of sympathetic magic, namely that publishing ones work in a fake scientific journal will result in real scientific progress. Whether the “metabolic cure” is truly a panacea or not remains to be rigorously tested. Whatever the outcome, the rituals practiced by the cargo cult of critical care must be questioned. Surely, if a plane did land on a Malaysian Atoll, it was not brought there by magic. What is the harm of joining the cargo cult? When pressed about their beliefs, practitioners typically rejoin that “vitamin C is harmless.” Medical science is the pursuit of truths that can benefit our patients. The innocuous vitamin C argument implies that finding harmless falsehoods is tantamount to beneficial truths. This argument ignores the fact that the effort expended building useless runways in the jungle could be better spent on any other endeavor. Finally, shaman make poor scientists. Embracing magical thinking undermines logical modes of inquiry, and by doing so we risk being drawn ever further off the path of true scientific progress. This is not to say that every ICU practice will be (or even could be) rigorously tested. Like the soldiers in the Pacific performing parade marches, an antiquated ritual in its own rite, some “proven” practices are clearly suspect. The cargo we seek is a noble one - a means to care for our patients - but we must avoid following “big men” and building straw aircraft to attract it. As Feynman cautioned over 40 years ago, "We've learned from experience that the truth will come out. Other experimenters will repeat your experiment and find out whether you were wrong or right. Nature's phenomena will agree or they'll disagree with your theory. And, although you may gain some temporary fame and excitement, you will not gain a good reputation as a scientist if you haven't tried to be very careful in this kind of work. And it's this type of integrity, this kind of care not to fool yourself, that is missing to a large extent in much of the research in cargo cult science." Nicholas Mark, MD (@nickmmark) is an intensivist in Seattle, Washington.