The College of Physicians and Surgeons of Ontario (CPSO) – the mandated regulator for the medical profession in Ontario – is currently reevaluating their standards governing the use of “Complementary and Alternative Medicine” or CAM. As others have pointed out, this classification of therapies is really quite dubious. Someone not familiar with the distinction between what we might call traditional medicine and CAM might wonder how such a distinction arose. From a scientific standpoint, would it not make more sense to classify therapies based on the level of evidence supporting them?

The key component often missing in the discussion surrounding CAM is that, while therapies traditionally categorized as CAM tend to lack robust supportive scientific evidence, there are many therapies with low levels of supporting evidence or plausibility that are not generally designated as CAM. Take, for example, the recent controversy surrounding off-label use of hydroxychloroquine to treat COVID-19. Though based on weak evidence and plausibility, the treatment was never promoted under the banner of alternative medicine. This is generally the case for treatments – even lacking robust science – that are at least founded on conventional models of human biology. CAM, on the other hand, tends to include therapies that are not just weakly supported by the body of evidence, but which are based on philosophies of health and science conjured up outside our mainstream scientific understanding.

Homeopathy is a perfect example of this. If one looks to the literature for clinical data supporting homeopathy, the outcome of such a review might yield similar levels of supportive evidence when compared to hydroxychloroquine. Yet, homeopathy is distinctly a CAM therapy because its suggested mode of action in the human body cannot be reconciled with our current understanding of biology and chemistry. Instead, homeopaths posit an alternative model of human biology and chemistry that lacks a supportive body of evidence. In essence, what distinguishes homeopathy is not the lack of clinical evidence supporting it, but the underlying ideology that ultimately calls into question the plausibility of a therapy.

Of course, homeopathy is so far-fetched and lacking in plausibility and supportive evidence that it should not be found in any physician’s practice (nonetheless, it persists). But it’s perhaps not appropriate to dismiss all therapies simply because they were founded on pseudoscientific models of health. Acupuncture (now often referred to as “dry needling” to discard the historical baggage), for example, has moved somewhat into the mainstream as its mechanism of action has been reframed as biomedical, rather than vitalistic. I personally find the supportive clinical evidence unconvincing in demonstrating a meaningful benefit from the therapy, but it may be a treatment more worthy of reconsideration given the mixed evidence and recontextualization within the modern medical paradigm. (As an aside, I highly recommend the book Snake Oil Science as an introduction to looking skeptically at such clinical evidence.)

The CPSO’s current CAM policy does not make the distinction on ideological grounds, but defines CAM as a nebulous grouping of practices and products that are simply not considered conventional medicine. The policy does not require any specific standard of evidence but stipulates that CAM-related decisions must be “informed” by evidence and science. The policy was put to the test not that long ago when Anne Borden King challenged a physician offering chelation therapy to autistic children. The therapy is without evidence of benefit, based on pseudoscientific principles around vaccines and autism, and comes with moderate risk, yet both the CPSO and the provincial’s appeal board took no action against the physician, indicating that no harm has been done yet.

The potential consequences of this inaction are worth considering. In this case, a physician was able to subject patients to a risky therapy justified not by robust science, but by the physician’s personal beliefs. The regulatory system made clear that there is no real scientific threshold by which therapies are judged. Instead, they appear content to let physicians sell any therapy – no matter how absurd – until it results in a direct (and documented) injury. Besides the obvious consequence of demonstrating that any nonsense is permitted under such terms, the decisions also implicitly rejected consideration of harms besides the immediate side effects of the given treatment.

Let’s further examine this specific case: the treatment of autism with chelation therapy. The treatment is typically predicated on a number of dubious axioms:

• Heavy metal exposure plays a causal role in autism
• Vaccinations expose children to heavy metal toxicity
• Removal of heavy metals can treat or cure autism in children

Of course, all of these claims are not supported by the science and by merely presenting this theory to patients, physicians are doing harm. The harm of such misinformation is not isolated to the clinic. Besides the unnecessarily expended time and money on useless treatments, patients (and their parents in this case) who adopt these views are prone to what we might refer to as secondary harms. How might these beliefs impact their willingness to vaccinate against deadly diseases? How might the idea that autism is a disease to be cured drive concerned parents to subject their children to unscientific and unethical “treatments”? To what extent do these beliefs drive patients away from conventional health professionals and services they may truly need? What is the societal impact of health misinformation?

These are just some of the questions that any serious health regulatory agency should consider when determining how best to protect patients and the public, yet Canada’s various self-regulating agencies have apparently not reckoned with the true reality of pseudoscience. It is perhaps with these concerns in mind that the CPSO drafted their proposed update to the CAM policy, which includes the requirement that physicians must practice “in a manner that is supported by evidence and scientific reasoning.” To what extent members are held to this, assuming it becomes policy, remains to be seen, but at least it codifies a standard necessitating that practitioners adhere to reality. A companion document, Advice to the Profession: Complementary and Alternative Medicine, provides guidance with respect to the levels of evidence. By suggesting the consideration of high quality scientific evidence, it’s a welcome addition.

Naturally, not all feedback has been positive. Despite its largely unsuccessful history in disrupting conventional care with useful therapies, CAM remains widely popular and is supported by a strong industry. We can find such support from a Toronto Sun article that palpably rejects the proposed reforms, arguing that the policy unfairly targets CAM providers, causing “fear they will be unjustly disciplined.” The article primarily relies on the trope that CAM offers a chance to patients who have otherwise fared poorly with conventional treatment. Unfortunately, people are not drawn to CAM treatments because they are effective, but because patients are dissatisfied with conventional care, wish to feel in control, and are sold hope in the face of despair. In essence, many of these practices are simply comforting myths, which can be quite convincing when paired with charismatic and empathetic practitioners.

A further argument made by the article is that the science-based standards would be too restrictive for a field where there is no money to be made from patents and, hence, “no incentive to finance the required evidence.” This is patently false. Ignoring the fact that the CAM-adjacent wellness industry is well funded, the recent history of scientific inquiry tells us that the issue is not a shortage of funding, but a shortage of plausibility and useful results. Take hydroxychloroquine again as an example. This drug is old, cheap, and patent-less, yet it received an extraordinary amount of research resources because it was at least a plausible treatment for a serious condition. Even outside of the pandemic, CAM treatments have not evaded research funding. Just look at the large literature base for acupuncture or homeopathy. Indeed, if anything, I would argue that such therapies have received a disproportionately high share of research funding when you consider their plausibility and outcomes.

Virtually all points raised in this article are similarly speculative; the author makes postulations that – just like the therapies alluded to – are not backed by strong evidence. She notes CAM providers fear they will be “unjustly disciplined”, but the CPSO’s failure to regulate even the most egregious pseudoscience is evidence that the opposite is true. Further, there would be nothing unjust about setting a universal science-based standard and disciplining practitioners who do not adhere to it. If practitioners think that medicine should not be based on scientific inquiry, I would suggest they find another career. After all, science is the method by which we determine which therapies work and which do not. The quoted anonymous practitioners claim to be “targeted” but they are only targeted insofar as they provide dubious treatments for profit. The choice is theirs.

I will agree with the author on one point: if physicians are always bound to making science-based decisions, why is a distinct policy needed for CAM? Shouldn’t physicians universally be required to make science-based judgements? Perhaps the policy is an implicit acknowledgement that practices categorized as CAM are those founded on pseudoscientific frameworks, but this would create a contradiction with a policy requiring a science-based interpretation and justification.

Regardless, the proposed policy has not yet been codified. If you are passionate about this issue, you have one more week (as of writing) to complete the online survey or post comments on the discussion page. I implore fellow Canadians to let the CPSO know that science-based standards are in the interest of patients and the public.

If you’re the Ontario government, you answered yes. In fact, the provincial government was so impressed by a specific application of this technology that they committed $2 million in funding. There’s just one problem. Well, actually, there are many.

CEM Specialties Inc.’s (CEMSI – based in London, ON) Kontrol BioCloud is a device its inventor describes as a “game changer” in the fight against the SARS CoV-2 virus. The device was designed to be installed in a room where it will continuously monitor the air for traces of virus. Upon detection, the system sends alerts to those designated to receive them, empowering them to make decisions based on the presence of the virus within their facility. The device’s promotional material asserts that these decisions will help mitigate outbreaks and speed up contact tracing.

CEM Specialties Inc’s president Gary Saunders has said this technology will further help diminish the spread of the virus. Across a number of press releases and interviews, the company and its representatives have floated potential clients for these devices: schools, hospitals, factories, transit systems, etc. Essentially, every shared space where there is concern of COVID transmission is a business opportunity. According to Kontrol Energy Corp. (parent company) CEO Paul Ghezzi, “BioCloud will not just monitor air quality, it seeks to create the conditions for Canadians to safely and confidently return to their jobs and their schools.”

This all sounds great, of course. Wouldn’t you want to know if you were breathing in the virus? Wouldn’t you feel more comfortable sending your children to school knowing they are monitored by the eager sniffer of a BioCloud? Don’t you want to put anxious people at ease so we can all return to work and “get the economy going”? BioCloud and its possible use cases are very compelling, which is precisely why the device should be examined with a skeptical lens.

If there is one lesson I hope the public has learned from this pandemic, it’s this: public health is not simple. From issues of basic science to questions of how interventions play out in practice, our assumptions and intuitions are contingent on science, which is often complex and even clumsy when it comes to large scale public health interventions. Many factors that might influence outcomes are not trivial to investigate, and even coming up with a model that takes such factors into account is a daunting task, typically refined by iterations of research across the scientific establishment.

With the real life complexities taken into consideration, I will attempt to address how we might answer the question: is the BioCloud product a viable public health intervention? We can decompose this question further into two primary concerns:

1. Does the BioCloud device function as advertised?
2. Assuming a working product, is it an effective solution to mitigate the spread of the virus?

Deciphering the hype

At time of writing, there are no publicly available demonstrations of BioCloud units, no peer reviewed publications, no regulatory approvals, no public health endorsements, and no approved patents. The device is not authorized by Health Canada, which means it cannot be used as a medical device to diagnose. With no information available from independent institutions or regulators, info about the device must be derived from publications by the company and the largely uncritical media frenzy that has followed.

Focusing on the detection capabilities, let’s begin at a high level with relevant technical specifications of the device as described throughout media releases and marketing material:

• The device is to be installed in indoor spaces up to 1,000 square feet or 225 cubic meters (the white paper also provides detection time calculations for rooms up to 2,500 square feet).
• The device samples the air in “real-time” (5 times an hour) to detect the SARS-CoV-2 virus.
• The “advanced” sampling technology “optimizes” the air for analysis (whatever that means).
• The device uses a proprietary detection chamber. Presumably, the undisclosed patent applications relate to this tech. There are apparently 3 USA and 1 Canadian patent applications that have been submitted.
• The device uses “three independent [virus] capture techniques that allows for intact virus sampling while achieving a high capture ratio.”
• The device uses “both a viral collider and a chemical process to trap virus particles.”
• The chemical process involves an unnamed reagent that is currently sourced from the US.
• The SARS-CoV-2 virus is ultimately identified with a laser sensor.
• Lower detection is based on detection of the live virus at 0.005ng, though laboratory tests allegedly found a sensitivity to 50 virus particles at the lower end.
• As far as I can tell, no human interaction/maintenance is intended to be required during operation with the exception of cleaning and detection chamber replacements, which occur 3 times a year, or following a positive detection.
• Kontrol provides estimates of detection time that range from 6 minutes for a 1,000 square foot space to 15 minutes for a 2,5000 square foot space (based on a number of assumptions).

I have excluded specifications relating to connectivity/alerting as these are technically trivial and uninteresting (though someone may want to follow up with the possible security concerns of a such a high stakes device supporting numerous network protocols).

According to the BioCloud reference white paper, independent lab validation was performed by “leading virology and microbiology experts” at the following labs:

• Heinrichs Lab (Dr. David Heinrichs)
• Dikeakos Lab (Dr. Jimmy Dikeakos)
• ImPaKt Lab

Dr. Heinrichs himself is quoted as saying “There’s no doubt in my mind that this technology can quickly and effectively detect an array of airborne pathogens, including the virus that causes COVID-19. Our results are absolutely conclusive.” It is not entirely clear what Heinrichs is referring to when he says “this technology.” I reached out to both David Heinrichs and Jimmy Dikeakos, but received no response.

While reports indicate that testing has been performed on a fully operating prototype, this does not appear to be the case based on how the results are reported. This may be due to inadequate documentation; overall, the experimental descriptions and supporting images are unclear and insufficiently detailed and labelled. Personally, if I was demonstrating a scientific achievement with an intent to commercialize, I would make sure that I communicated the important details in such a way so as to render the results unquestionable.

If you scroll to page 15 of the white paper, you will find the opening page of the publicly available findings related to testing of the device. The following page documents the detection process: a “viral target” captures SARS-CoV-2, a reagent is introduced that binds to the virus, then a laser is used to detect the presence of the virus. The process makes sense and is well illustrated within the accompanying figure, but the subsequent experimental documentation raises concerns.

In short, the experiments seem to indicate that a nitrocellulose membrane coated with a receptor protein is repeatedly washed with samples from the air as well as the reagent. After the “the reagent detection sequence,” a “measurement sequence” is performed (no details given). Presumably this last step would be the laser’s role, but throughout the experiment, the paper was only ever said to be “inspected”. There was no laser described or shown.

Considering the absent laser component, a fully working prototype did not appear to have been tested. In addition to the laser, the device would presumably need to recycle the requisite testing materials for sustained use. This would include the nitrocellulose, receptor protein, reagent, and the various solutions utilized. To operate as advertised, this process would have to occur over and over again within the machine without human interaction.

Based on the replacement frequency of the detection chamber, and assuming that the machine operates 5 days a week for 8 hours, the BioCloud would have to perform over 3,000 tests without intervention. In my opinion, this is the more remarkable feat than demonstrating a one-time detection event, but there are further challenges still when attempting to align the testing with the claims made for the device.

Even if we assumed that the device was fully functioning and could perform sustained sampling and testing of the air, we have no idea how it will perform in the real world. Whereas the lab presumably provided a controlled environment with limited air particulate, the intended deployment environments are surely not quite as ideal. How does the device remain reliable for extended periods of time when cycling through the air? Are there conditions that may result in false positive detection events? How does the device ensure the extended lifespan and integrity of the compounds/materials it uses? These questions are unanswered.

Even the calculations estimating the detection time (extrapolated from ideal testing conditions) require a number of assumptions unlikely to hold true in deployment scenarios. In particular, the calculations rely on the presence of a model of a COVID-19 “high emitter” who breathes regularly and coughs once per air exchange. We will return to this assumption later, but it is worth noting that this excludes low or even moderate emitters.

The concerns raised up to this point, if left unaddressed, should be enough to preclude the deployment of this device as a public health intervention. Not only can we not be sure the device fully works, but there is no firm evidence that it can function effectively within environments it is intended to safeguard. Nevertheless, let’s go a layer deeper as devil’s advocate and speculate on the value a fully validated (functioning) device of this nature might offer.

(As an aside, it is also worth noting that there are some mistakes in the white paper that would have been caught by a seasoned reviewer. As perhaps the most egregious example, one of their references [9] lists only a title and a school with no indication of the format or how it was retrieved. It does not appear to be available online and does not appear to be an actual scientific publication, which is unfortunate, as it is referenced in support of a strong claim.)

Life in the real world

Public health considerations are often more complex than they might seem at first. In part, this why public health positions on mask use evolved over time. In addition to questions about how the virus spread and how effective masks were when utilized by the general population, there were also initial concerns about shortages for medical personnel, which could have had drastic consequences. There are further concerns about the use of improvised or inappropriately fitting masks, which may give people a sense of security without offering significant protection to themselves or others. Even knowing that respiratory droplets are a potent transmission route for the SARS-CoV-2 virus and that face masks generally mitigate the travel of such droplets, it was difficult to estimate the benefit at a population level because of the complex factors surrounding the use of masks in our everyday lives compounded with uncertainty of viral transmission specifics. The possible benefits the BioCloud might provide are even more of a mystery at this time.

First, we have to contend with the fact that the BioCloud is perhaps least likely to find itself in the idealized situation such as those at the foundation of the white paper’s calculations. Recall that one of these assumptions was the presence of an actively coughing COVID-19 “high emitter.” So-called high emitters would undoubtedly stand out in a COVID-aware world. Even without a cough (which alone would defeat the assumptions behind the model), workplaces, businesses, and many other places where people gather increasingly screen for symptomatic individuals and may have a strict policy for people experiencing even one of a number of symptoms.

In areas where such screening occurs, we might expect to see spread primarily from asymptomatic people or people whose symptoms are not visible. While such individuals can spread the virus, they are likely not quite as efficient as symptomatic carriers. Of course, this presents an additional impediment to the possible performance in the real world.

One term oddly absent from the analysis and assumptions regarding this technology: masks. Masks have become commonplace in indoor settings where people gather to work in close spaces. While this isn’t universally the case, I suspect it represents the majority of locations considered. Since we know various types of masks mitigate the amount of expelled virus, it is safe to assume that mask wearing would further impede the likelihood of a unit from detecting the virus.

With these few realities taken into consideration, the likelihood of the device actually detecting the virus in a short time in practice is looking to be questionable, but there may nonetheless be some situations where it gets just what it needs: a dose of unmitigated virus right into its detection chamber. Such a situation would include indoor spots where people gather without full compliance to public health guidelines and without direct supervision or screening.

Two possible hotspots that came to mind were certain churches and mass transit such as the Toronto subway, but the former is likely to not buy in to detection technology (even if it worked) and the latter is of questionable value when people are either stuck on a train or moving around the terminals. With people constantly on the move, what value is a detection event that lags 6 minutes at best? What are operators to do when the sick individual has moved on and the virus has already been spread?

Let’s once again – for the sake of argument – dive to a deeper layer of hypotheticals and assume that there exist indoor spaces that satisfy all the assumptions behind the product where both uninfected and “high emitter” individuals congregate for long periods of time. What happens when the BioCloud unit detects the virus?

The team behind the device has indicated that the decision making process following a positive result is up to the management at that facility. So what, then, is a facility to do upon detection? Do they evacuate? To what extent? Is everyone in the facility tested? What happens over the subsequent days? What liability might a company take on with respect to their response?

These are just some of the questions that should be addressed not just prior to deploying the device, but in preparation for conducting an actual clinical trial to demonstrate value. After all, the BioCloud is backed by claims that it can help stop the spread of the virus. To prove that, we would need to study a fully working unit in a real setting with well-thought-out procedures. But again, for the sake of argument, let’s assume that all this work had been done and a study was published showing at least modest reduction in positive cases where units were deployed. We would then ask: is it worth the cost?

All health interventions must consider both the benefits and the costs. We could, for example, perform a COVID assessment (nasal swab) of every Canadian, 3-times per day. We would find more cases, allowing us to quickly isolate those infected and mitigate spread. Would it be worth the cost? I’m no health economist, but I am going to suggest that it would not be.

The BioCloud is priced at $15,000 (on the low end) with a maintenance cost likely around $2,000 per year. Is it worth the cost? The answer depends on a great number of factors that we simply do not know. This makes it a rather high stakes bet, especially for potentially high risk settings that are already strapped for cash.

Where are the scientists?

For a novel technology like this that appears to be the first-if-its-kind on the market, there must be scientists behind it, no? Oddly enough, I could not identify an employee of CEMSI with what I would consider a sufficiently relevant scientific title or background. Just take a look at the LinkedIn listing of employees (disclaimer: LinkedIn is never a comprehensive employee list).

While the company does appear to have some experience with technology that makes up components of the BioCloud, the key components that drive the detection process cannot seemingly be traced back to a laboratory or scientific group. This may seem like a strange way to assess the validity of the technology, but tech of this nature often possesses a scientific lineage that consists of basic science research, early prototypes, publications, etc.

It may be that the company has found a very creative way to repurpose existing technologies into a fully automated product. It may even be that the company has developed entirely novel processes that have evaded scientists working in this area. I am open to being proven wrong, but I am skeptical of these possibilities. Don’t get me wrong, I love the idea of people outside the scientific establishment inventing novel and practical science-based tools, but history is not necessarily in their favor.

I do understand that there exists motivation for secrecy. If the company does have a brilliant product, it would not be in their interest to reveal sufficient information to permit reverse engineering, especially as they do not yet hold patents and there is no guarantee that their applications will be granted. That said, I would be much more reassured to see public support for the product beyond that coming from the company and its apparent shareholders. If you search Twitter for BioCloud or $KNR, for example, you will see unrelenting promotion from accounts that appear dedicated to boost the company’s stock. Of course, I am not claiming that these are bots or paid accounts; they might just as well be investors with a stake in the company. The accounts range from clearly dedicated investors to accounts that have been inactive for years before taking a strong stance on the product and company.

As mentioned earlier, David Heinrichs is the only researcher who was quoted in support of the technology, yet I cannot find any statements he has made about the device besides the primary quote repeatedly attributed to him. I find it odd that he wouldn’t simply respond to my email reassuring me that the device works and that he stands behind his claims and testing. He may certainly be bound by some form of non-disclosure agreement, but I still find it odd that he wouldn’t confirm this restriction or even affirm his published comments.

When I reached out to other experts in this field, they were skeptical, noting the device’s white paper did not contain sufficient information to determine whether the BioCloud worked and how. Others on Twitter (an investor and financial crime expert) shared similar concerns about the lack of public scientist support shortly after the device was first announced. The most relevant credentialed public support for the device I could find was a Newfoundland-based former dentist whose apparent sole tweet (at time of writing and assuming that this is not an impersonator) appears to be no different than the hoards of presumed shareholders spamming social media in a likely attempt to bolster their investments.

Just as curious as the development, one manufacturer contracted to actually make the devices (or at least components of them) is OES Manufacturing – another company in London, Ontario that specializes in making sports scoreboards and wire harness quality assurance devices. They appear to work with a variety of industries, presumably in the design and manufacturing of circuit boards, but it is not clear that they possess sufficient capabilities to manufacture what might be required for a functioning BioCloud device. Then again, without sufficient technical information, it is impossible to know just what the manufacturing requirements are and we do know that some components, such as the reagent, are externally sourced.

I reached out to Brad Young – the BioCloud Technical Manager. My first interaction with Brad was on Twitter, where he wouldn’t confirm with me that there existed a fully functioning prototype, instead posting a picture of some units that did not appear finished. In his defense, he is not very active on Twitter, but I find this a strange question to leave unanswered, especially after initially engaging me. I followed-up with an email to Brad, asking if he would be willing to answer some questions or put me in contact with someone who could. I never heard back.

Skepticism, but not absolute

It should be clear from my writing that I am highly skeptical of this product. I am skeptical that it works as intended. I am skeptical that it can perform sufficiently in real world scenarios. I am skeptical that it has value as a public health intervention and I am skeptical that its cost would be justified in many of the target settings.

I am equally skeptical – as everyone should be – of companies that hype novel technologies without providing sufficient supporting evidence or demonstrations. When it comes to publicly-traded companies, shareholders don’t just stand to benefit from revenue, but from speculation on the value of the stock. I don’t possess the expertise to analyze the business elements of this situation, but others have suggested some interesting trends. Then again, a company can hardly be blamed for capitalizing on opportunity.

Nevertheless, I am not so skeptical to conclude this product definitely cannot work. I won’t even claim that it has no possible value as a public health tool. As a science advocate, I simply demand a higher level of evidence. As a taxpayer, I can only hope that the Ontario government was provided with such evidence.

Let me preface this article with my position on patients who are mislead by health professionals: these people are victims. I do not believe this makes all patients immune from criticism when they defend abhorrent practices, but it is worth keeping in mind that – between the patient and the caregiver – only one of these two has a professional obligation to disseminate reliable, science-based information and provide informed consent. With that in mind, this post is a rebuttal to a chiropractic patient’s perspective published by a group that advocates for various forms of pseudoscience. From the piece:

A common-sense piece of information – that misalignment equals stress, equals weakened immune response, equals heightened vulnerability to the COVID-19 pandemic – had been conflated into an outlandish accusation that chiropractors were claiming that chiropractic treatment would make one immune to the novel coronavirus and prevent COVID-19. Quite a stretch. But is it really so far-fetched that a healthy spine can improve one’s ability to fight off the coronavirus should one contract it? Or that an individual might suffer milder symptoms should they develop COVID-19? I think not.

Claiming that something is common-sense neither makes it so, nor does it make that belief true. Throughout the relatively brief history of science, there have been numerous cases where common-sense (what we might refer to as conventional wisdom) has be overturned by rigorous experimental science, producing results that differ from what was expected. This has been discussed to such great lengths that I won’t go into further detail here. The internet is your oyster, friends.

What I will dive into are the assumptions in the quote above, which are not-so-subtly glossed over. The first contention is that misalignment equals stress. This can be debunked without understanding it within a chiropractic (vitalistic model, to be clear) framework. There is substantial clinical evidence to inform us that just because something may appear to be misaligned or abnormal, does not mean that there is a real impact to a patient’s well-being. This has been an increasing concern with widespread use of advanced diagnostics that turn up incidental findings. Ironically, the treatment of these findings has – in some cases – lead to unnecessary harm as patients are subjected to therapies that carry risk for something that did not need to be treated.

This type of over-treatment is especially true for chiropractors who claim to diagnose and treat vertebral subluxations, which is the term most commonly used to refer to such misalignments. The major difference between medical over-treatment and over-treatment of subluxations is significant, however: subluxations – as defined by vitalistic chiropractors – do not exist and cannot be identified using any diagnostic technique. Don’t take my word. Refer the opinion of contemporary chiropractors, their associations, or chiropractic research if you must. On the immune issue, why not also check in with Canada’s largest chiropractic association, who are clear that “there is no scientific evidence that supports claims of a meaningful boost in immune function from chiropractic adjustments.” Interesting how this is left out of the article, no?

Regarding the claims that stress leads to a weakened immune system, leading to an increased susceptibility to COVID-19, these claims are plausible, but without clinical evidence, we can’t know if there is a meaningful impact nor if there was an approach to reducing stress that could meaningfully reduce your COVID-19 risk. Remember: common-sense is distinct from truth. Scientific methodologies are the best tools we have to overturn our false, preconceived beliefs. This is an ongoing effort in medicine.

In regards to the so-called “conflation,” I don’t recall identifying a chiropractor who guaranteed patients receiving care would not get COVID-19, not would I make such a claim; however, perhaps this was not directed at me. I will affirm that it is “far-fetched that a healthy spine can improve one’s ability to fight off the coronavirus should one contract it.” This is absolutely far-fetched, as should be clear at this point.

The author went on to cite a video from a chiropractic marketing firm run by the dubious Heidi Haavik, whose “research” assumes vitalistic philosophy a priori. I will be writing a post on Haavik and her bad science soon enough. For now, I will note two things about the video:

1. This is not scientific evidence, but a video constructed by a chiropractic marketing firm to deceive patients in order to make money.
2. The video constructs a reasonable narrative about the importance of the spine/brain, but concludes with nonsense that has no basis in science. Go ask Haavik for clinical science demonstrating meaningful benefits that would support her claims. There is nothing; this is smoke and mirrors.

The author goes on to cry fowl on the unimportant distinction between chiropractors offering some immunity benefits compared to chiropractors offering absolute immunity against COVID-19. These claims are different in magnitude, but they are both false. Again, I try to put great care into my own claims and doubt I have made the suggestion that chiropractors guarantee absolute immunity. She continues:

I also noted in my rebuttal that even yoga can improve overall health by reducing stress. And what do yoga and chiropractic have in common? They are all about alignment. They also both promote better breathing habits. Anyone who has taken a yoga class will know that breathing technique is very much incorporated into yoga practice. As for chiropractic, anyone with a bound-up spine and adjoining muscles will know that constricted muscles around the ribcage – which attach to the spine – will inhibit the ability to take a full breath. When one muscle or joint doesn’t move properly, other muscles will compensate, and before you know it, your whole body is in knots, which causes all kinds of stress, which can depress the immune system. More on that later.

Yoga probably can improve some facets of one’s well-being. It is, after all, simply exercise. I am not aware of any clinically demonstrated benefits derived from yoga’s stress reduction, however. The notion that yoga and chiropractic are both about “alignment” is nonsense. Again, contemporary chiropractors do not play make believe with their patients’ spines, pretending to correct non-existent misalignments. We can have a debate about whether spinal manipulation offers truly meaningful benefits for back and neck pain, but that it out of the scope of this discussion.

Further, there is absolutely no reliable evidence that spinal manipulation (or “adjustments” for chiropractors who got their education by applying to a school through a magazine ad) provides any benefits towards taking a “full breath.” In fact, research into chiropractic treatment of asthmatic patients has failed to elucidate any objective benefits for lung function, despite great efforts. To see how some chiropractors still spin negative results to fit their ideology, check out the conclusion of this sad paper. Returning to the article:

The news report makes much of “one Ontario man” who had submitted at least 34 complaints against various chiropractic clinics, citing “misinformation” regarding the health benefits of chiropractic. Ryan Armstrong, with his PhD in biomedical engineering, heads up an organization called “Bad Science Watch,” which according to its website is “an independent non-profit consumer protection watchdog and science advocacy organization dedicated to improving the lives of Canadians by countering bad science.” Armstrong’s conclusions about the efficacy of chiropractic in boosting immune system function are based on a lack of science, or more accurately, on his inability to find any. “There’s very immediate harm from this type of misinformation,” he says. Indeed, making assumptions and publicly dismissing claims of health benefits based on a lack of information, rather than on evidence that the claims are false, is truly harmful and bad science.

I’m not sure why the emphasis is put on “one Ontario man”. Do you disagree? Just to be clear, my personal activism from complaint writing is distinct from our work at Bad Science Watch, though we do have our sights set on this area of activism. Now, with that all cleared up, let’s address the author’s very limited and naive understanding of what science and evidence are.

What is science? What is evidence? These are philosophical questions that are far beyond the scope of both this post and my expertise generally (though I do read all I can on the philosophy of science and recommend so for anyone in science advocacy). Unfortunately, there really are not universally accepted standards that allow us to reliably determine what is science and what is not. This is known as the demarcation problem. I encourage the author to pursue some reading in this area. I think she will find it both enlightening and enjoyable.

The best I can do here is to tell what I mean by these things. Typically, I use science and evidence as short-hands. What I mean by science is close enough to the Wikipedia definition: the “systematic enterprise that builds and organizes knowledge in the form of testable explanations and predictions about the universe.” When one claims to be fitting pieces into our collective knowledge that do not appear to belong based on their incompatibility with existing knowledge and their lack of experimental rigor, I deem this to be bad science. This obviously includes the classic notion of the vertebral subluxation.

When it comes to evidence, I typically mean reliable evidence, leaving the reliable component to be assumed. Evidence – broadly speaking – is anything that is used to used to support a claim, but I find the term to be largely useless when used this way. To offer an example, you might tell me that there is no evidence that all of the vitalistic chiropractors across Canada have formed a death cult intending to bring about the destruction of the planet. After all, that is an absurd assertion. I would simply counter your point by saying I heard it from someone. You might say “well that doesn’t make it true,” and you would be right; however, it still constitutes evidence by definition. Is it reliable evidence that we should accept as truth to make better decisions? No.

When claims such as those made by chiropractors implying immune benefits are made, they should be dismissed for two reasons. The first reason is that they do not fit into our most refined and accepted scientific theories and paradigms (in fact, they contradict much of our understanding of human biology). The second reason is that there is no reliable evidence in the form of clinical trials looking at meaningful clinical outcomes supporting these claims. They fail on all counts.

You might think that it is “exceedingly difficult to either prove or disprove in a measurable scientific study that a chiropractic adjustment has a direct causal effect on improved immune system function” but this is false; you simply lack imagination and presumably a scientific background. I can think of a very simple trial design:

1. Randomize two large groups of subjects between real manipulation and sham manipulation.
2. Have subjects come in to clinics on a regular basis to receive their “treatments” over the course of maybe 4-12 months.
3. Measure a number of meaningful clinical outcomes: number of sick days, duration and incidence respiratory symptoms, hospitalization, other cold/flu symptoms, etc.
4. Make sure to do better than all other vitalistic chiropractic studies (well, we already are by having n>1) and control for the multiple endpoints when you compare outcomes.

There is a reason such a study has not been performed, and it is not because there is a global conspiracy against the minority of chiropractors who believe this nonsense. The study would not meet the minimal requirements to be deemed ethical nor would it meet the requirements to be funded by a granting agency. The cause for both of these is the same: the foundation for these beliefs is not in sound science, but in an outdated ideology.

Keep in mind, this is not for lack of trying. Vitalistic chiropractors have been trying for decades to (mis)use science to prove themselves correct. Despite significant efforts (largely through dubious special interest journals), they have failed. So although it would not be philosophically accurate to say that chiropractic immune claims are “disproven”, it would very much be pragmatic to do so, as the foundational ideas have so thoroughly failed every test that there is little more we could do. At very least, it would be deceptive for practitioners to suggest that they may benefit immune systems with a spine rub. If you don’t accept this, then you must also believe it acceptable for pharmaceutical companies to make any unproven claim for their products. Naturally, I object to both. Fraud is fraud.

With that said, I am confident to assert that spinal manipulation does not offer a real benefit to one’s immune system just as I am confident in asserting that there is no teapot between Earth and Mars that is orbiting the sun (I am sure it is just a matter of time before Trump’s Space Force inserts one, however, thereby proving God’s existence).

The author continues by grappling with statements made by friend of the blog Tim Caulfield. This next bit is staggering.

Caulfield said that he couldn’t find any evidence to support that 200% increase, in particular, and not that he couldn’t find any evidence of an increase in function at all. Not to mention that his search for this study consisted of a “quick Google search,” which apparently was fruitless, and which the CBC is implying as evidence that the study doesn’t exist. That’s just misleading representation of his words and shoddy reporting. Even if that is exactly what he meant by referring to an “alleged author,” implying that the study is fabricated by the chiropractic community to support their claims, again, it was sloppy journalism on the part of the CBC to blindly accept that and promote that interpretation. There were three journalists on this story – did none of them have the time to bother looking for the study themselves?

By the way, Tim Caulfield and Ryan Armstrong, to your claims that “there is no science behind it,” my own “quick Google search” yielded this “partial list” of 114 citations regarding the effects of spinal adjustment on immune system function, including the one Tim couldn’t find by “alleged author” Dr. Ronald Pero, PhD, chief of cancer prevention research at New York’s Preventive Medicine Institute and professor of medicine at New York University. Fill your boots.

https://healthsourcelombard.com/does-chiropractic-strengthen-immunity/

Let’s address the funny part: the author takes great issue with the suggestion that the chiropractic community has collectively manufactured a fabricated reference purporting that “adjustments” can boost the immune system by 200%. Why is this funny? Because that’s exactly what has happened here; this so-called study is nothing more than a fabrication. This is even recognized and refuted by evidence-based chiropractic groups.

So if the study is a fabrication, what exactly did the author cite to prove its existence? She cited a chiropractic clinic’s website, that simply contained the following reference:

Pero R. “Medical Researcher Excited By CBSRF Project Results.” The Chiropractic Journal, August 1989; 32.

You’re permitted to have a laugh here, reader. Even if we were to assume that the referenced article existed at one point in time, it is obviously not what practitioners purport it to be. At best, it appears to be an opinion piece published in a special interest chiropractic journal probably misquoting or misrepresenting a researcher over 30 years ago. Perhaps the author’s time would have been better spent asking chiropractors citing this why they have no respect for their patients or for science broadly? If her own chiropractor put her up to this, I implore her to ask the practitioner why they have so little respect for her that they would suggest a source without performing high-school level fact checking.

The second contention made by the author in the above segment is this: because a Google search of hers yielded many results “regarding the effects of spinal adjustment on immune system function,” there therefore is ample evidence of such effects. It is worth keeping in mind, dear author, that not everything you read on the internet is true or reliable. This is especially the case for these types of studies which do not contain any reliable evidence. Would you rather hear this from chiropractors? How about the most prominent international chiropractic association, which reviewed the available evidence on this topic and concluded:

No credible, scientific evidence that spinal adjustment / manipulation has any clinically relevant effect on the immune system was found. Available studies have small sample sizes and a lack of symptomatic subjects.

At the time of writing, there exists no credible, scientific evidence that would permit claims of effectiveness for conferring or enhancing immunity through spinal adjustment / manipulation to be made in communications by chiropractors.

I would also like to draw the author’s attention in this report to yet another dismissal of the alleged Pero study contained within the WFC’s report:

Overview: It has been reported that in 1986 Dr Ronald Pero, a Professor of Medicine in Environmental Health at New York State University, collaborated with Dr Joseph Flesia, a basic science researcher and
chiropractor. Reports state that subjects receiving chiropractic care (n=107) had a 200% greater immune competence than those who had not received chiropractic care and a 400% greater immune system competence than those with cancer or other serious disease.
Response: Numerous attempts have failed to retrieve this study. Without the original study to review, no scientific assessment of its claims can be made. Therefore, the “Pero and Flesia” study does not constitute credible, scientific evidence that spinal adjustment / manipulation enhances or confers immunity nor should it be used as a basis to provide care.

The author continues, repeating many of the same ineffectual arguments in, invoking both common-sense as well as her own personal experience. She concludes her tirade against myself and Caulfield with the following:

So can chiropractic care help to ward off COVID-19, just like any other virus? Of course it can. I believe retractions by the CBC, Ryan Armstrong, and Tim Caulfield are in order.

How ironic that the CBC should choose to end the news report with Ryan Armstrong’s statement that this “misinformation” about chiropractic “undermines our democracy.” I fail to see the democracy in the act of making sweeping one-sided statements based on a lack of information and understanding, particularly when, by his own admission, he has never been to see a chiropractor himself. I, for one, suggest that anyone who insists on discrediting an entire health care profession and dismissing the benefits it claims to offer needs to try it first before passing judgment. Far from doing the Canadian public a service through his work, he is dissuading us from availing ourselves of a valuable tool for improving and maintaining good health. This is particularly disadvantageous at this unprecedented time in history with worldwide quarantines, resulting in widespread job loss, leading to high levels of stress across the planet.

Here is my own conclusion, which – not that it matters – is in agreement with contemporary chiropractors and their associations: chiropractic care does not help ward off COVID-19 nor any other viral contagion. Chiropractors who continue to deceive patients otherwise are effectively committing health fraud while continuing to embarrass a profession with a reputation that hangs on a thread. Equally ironic and sad, my predictions have been fulfilled; chiropractors have disseminated misinformation in a way that has made their victims committed warriors of pseudoscience, weaponizing nonsense in another misleading article that orbits the world of health policy and regulation.

Finally, to the author I say this: I hold ill will against you. You have been mislead and deceived for profit. Your chiropractor has failed in their obligation to adequately inform you on serious matters of health and they have failed in their responsibilities to continue learning and remain competent. Just as troubling is to see your piece published by an organization guilty of consistently spreading health misinformation, whose Board of Directors all have direct stakes in the “alternative” health industry.

It is precisely because these forces are pitted against patients and the public that I feel science-based activism is more important than ever. And I will keep fighting for your rights as a patient even if you feel the need to attack me for it.