Part 2: Marik, sepsis and self-plagiarism
Marik is a retired professor and clinician. FLCCC is his current affiliation. Wander the site and you stumble upon hokum right away: talk of naturopathy and musings on Big Pharma's strangehold over Western medicine. We head to the About tab which refers to Marik's "revolutionary work in developing a lifesaving protocal for sepsis". Here they are alluding to the HAT protocol: a combination therapy of vitamin C, hydrocortisone and thiamine which failed to impress in clinical trials. See, e.g., the VITAMINS trial comparing HAT with hydrocortisone alone.
These studies, led by academic investigators, suffer methodological problems: ad hoc composite endpoints (often infused with subjective measures) are appealing due to the small sample size and low event rates, but they are crude and overestimate power at the design stage leading to equivocal results and a lack of reproducibility. Academic clinicians have pushed composite endpoints over multivariate alternatives due to ignorance and they now pervade the literature despite the limitations. (More about this in Part 4.)
Marik espousing HAT is apparently not to be compared with a drug company pitching its drug, even though Marik's reputation (according to the FLCCC website itself) coincides with its success and is reminiscent of pharma's control of the perception of its drugs; Marik can be found on youtube, in a video created by his institution, describing how he saved a woman’s life and landed on his combination therapy with vitamin C.
The reader should be aware that disputes among academics over treatment alternatives often become heated; they seem to think there's a lot at stake. Consider Milton Packer and discussion around SGLT2 inhibitors and GLP-1 agonists. These are not good-hearted discussions. They are small-scale battles with a lot of vindictive plays going on behind the scenes. E.g., reviewing a paper harshly if the data deflect from the pet theory, and, when this fails, persuading the editor to allow a rebuttal in the form of a letter-to-the-editor.
These incentives are not flagged by either Marik or Boghossian. Instead, with his blinkered view, Marik goes so far as to say: any trial funded by Pharma cannot be trusted, even when the trial is conducted by academics. We are expected to believe that academics are trustworthy up to the point that they come into contact with Pharma, then they are utterly venal. But how does Marik think they rig a multi-million dollar clinical trial? We will get to this in subsequent posts.
Sepsis is rife with hopeful claims like Marik's precisely because of the lack of breakthroughs that have been made (the “need for systematic improvement in the initial management of patients“ and "what's next?"). This draws ambitious researchers and low quality trials that generate ambiguity allowing room for claims that would be thwarted by a robust RCT. The field is especially vulnerable to academics peddling black-box AI and machine learning tools (e.g.: TREWS machine learning-based early warning system for sepsis). Suchi Saria built a company (Bayesian Health) around her sepsis detection tool and the website has the same appearance as a drug company’s.
The astute reader will wonder at this point: academics peddling tools is perfectly analogous to the drug company marketing its drugs? Almost. The only difference is that, despite calls for RCTs of the machine learning tools comparing patient outcomes, the academics do not run them and in their absence hype is nurtured: “There is ... a tendency to over-claim the potential usefulness of ML models for clinical practice … The next body of work that is required for this research discipline is the design of [RCTs]“. If you do not test against standard care in an RCT then your research paper amounts to marketing material.
Given Marik's posturing we might expect him to be bleating about unsupported claims coming from academics who are celebrated by credulous science magazines: "Algorithm That Detects Sepsis Cut Deaths by Nearly 20 Percent." It is not as though these tools cannot do harm just as drugs can. Perhaps more so as they influence patient care and triage and do not undergo proper validation and regulation.
The motivation for the discussion with Boghossian is Marik's concern about perverse incentives affecting medical research; he cannot relent we are supposed to believe. But we witness here the uselessness of his fixation. In the scenario described above pharma play no role: we noted how academic disputes affect the publication process and how lower quality studies generated by academia tarnish the collective pool of results. Yet Marik laments pharma exclusively. Why doesn't Boghossian call it out? Is it not apparent, even to an outsider, that science becomes indistinguishable from marketing when they rush to celebrate the academic’s product?
As companies praise their drugs, institutions praise their scientists. The academic sells himself: his 'lab', which he often names after himself, is defined by marketing, influence metrics, and an increasing use of social media where he touts his ambition and makes allusions to whatever is gaining traction e.g. big data. (Beguiled by the complexity of the subject, and in the absence of proper validation, it is pure marketing.) Overlay these pictures: industry employees celebrate their company when they win marketing approval and institutions celebrate their scientists when they win awards. It is the same but inverted. The academic's reputation is paramount just as the company's reputation must be protected.
Unsurprisngly, then, when Boghossian introduces us to Marik we learn that he feels unfairly treated by the medical journals who censured him due to recognised self-plagiarism. His reputation is under attack! It is remarkable that Boghossian laughs off the idea of self-plagiarism as if it is incoherent; he says you cannot steal from yourself. (Why equate theft with self-plagiarism instead of, say, forgery?)
There lingers an unannounced shift from his previous emphasis on the plagiarism scandal affecting academia - suddenly it's all a joke. He also does not flag Marik's perceived grievance as a source of resentment which would add context to his outrageous claims. (Maybe he left that for us to detect, to spare Marik the embarrassment.) This prelude feels like a hasty attempt to restore Marik's reputation before getting on with the relevant subject matter.
It was a superflous review article about his work that led to Marik's self-plagiarism. It is well known that academics enhance their publication count (and hence their reputation) by extracting as many papers as possible from the same data source. This leads to practical problems such as duplicated data in meta-analyses. How this biases results has been reported for several decades, e.g. from 1997: "Inclusion of duplicated data in meta-analysis led to a 23% overestimation of ondansetron's antiemetic efficacy." (This problem may now be excacerbated by tools used by thoughtless researchers that scrape papers for estimates for use in meta-analysis.) Often the author will not reference their own work to limit the risk that reviewers will detect the duplicated text; it is a very seedy business.
Marik is suggesting the medical literature is corrupt while muddying it with his self-promotional material. He says he wanted to "spread the word". They always speak like this, i.e. in euphemisms; we all know what is going on. It is worth keeping this maxim in mind at all times: pharma sell drugs, academics sell themselves. Once again Boghossian misses this in his eagerness to combat bad pharma's assumed pernicious influence.
From the outset, then, we have a picture of a man who is frivolous and sloppy, defiantly so, laughing off the affair. And he is a little befuddled and resentful: we are expected to infer that if he has been censured the only possible explanation is that something underhanded is going on, rather than simply: journals have standards. (Yes, this is ad hominem. There is nothing wrong with ad hominem. We are trying to understand Marik. The public expects scientists to be fastidious, pedantic even. It's a bad impression at a time when science is leaking public trust.)
Part 3, covering Marik's specific claims, will follow in some days. Hopefully in Part 3 we will also find time and space to consider: why did Boghossian fall for this? This is what we find salient. Podcasting at this moment feels precarious and untenable, yet unavoidable.