#NoakesHearing, day 1: Reflections on futility

hpcsaAs anyone who clicked through to this piece probably knows, yesterday saw the start of a Health Professionals Council of South Africa (HPCSA) hearing to assess whether Prof. Tim Noakes is guilty of unprofessional conduct. The charge against Prof. Noakes states:

That you are guilty of unprofessional conduct or conduct which, when regard is had to your profession, in that during the period between January 2014 and February 2014 you acted in a manner that is not in accordance with the norms and standards of your profession in that you provided unconventional advice on breastfeeding babies on social networks (tweet/s).

I attended all of yesterday’s session, and offer some thoughts on what transpired, below. I have not attempted to catalogue everything that happened – if you want a more detailed account, the News24 live-blog offers an accurate summary.

On futility – once more with the distinctions

It continues to exasperate that I can think of only one person a handful of people who understand that there are (at least) two distinct issues at play in the general discussion around Noakes, LCHF and Banting. The first is the set of questions related to diet, and which is healthier for you.

In this set of questions, I’m bundling in long-term vs. short-term, treatment for obesity and diabetes, what proportion of population X are insulin-resistant and so forth. I do not, in general, comment on those issues. They are not a field of expertise for me. As I’ve repeatedly said, Noakes might well end up being a frontrunner in what eventually becomes scientific consensus.

The second set of questions relates to logic and philosophy of science, and to our responsibilities as educators, or journalists, or health professionals to discourage sloppy thinking on matters of significance (well, on all matters, but the stakes are sometimes higher than others).

So, I’ve consistently (with a few lapses, I’m sure) focused on the quality of argument that emerges from the Banting camp, rather than on the superiority of any particular conclusion. If you don’t care about those issues (you of course should), then you shouldn’t be reading my comments on them.

You certainly shouldn’t be asking me to present evidence that low-carb is bad, because that’s not what I’m claiming. You also shouldn’t be telling me that “there’s so much more bad science for the consensus” or somesuch, because maybe there is, and maybe there isn’t, but that’s not what I’m talking about. The fact that someone else (proponents of the consensus view) also does things wrong doesn’t give anyone else a free pass to be sloppy in their reasoning.

On futility II – the hearing that never happened

We spend the entire day hearing arguments about the constitution of the panel that was set to hear the case, and proceedings were eventually terminated at around 15:30 when it was agreed that the panel was improperly constituted. Proceedings will resume on November 23, assuming nothing else interferes with the process.

Should this hearing be happening at all?

I have mixed feelings about this. As with so many of our policies (and even heuristics related to social interaction), there’s a vast difference between what made sense in a pre-digital era and what makes sense now. Noakes is often to be found on Twitter – he’s written an ode to it, in fact, and his fans love him for how much he engages there.

The point of highlighting the pre/post-digital era is of course it would be irresponsible for a physician to encounter you in the street and tell you what your baby should eat, unless your advice is something rather generic and consensus-based. Even if the consensus is wrong, as Noakes thinks it is, it does sit with an advantage here – his job is to create a new consensus, after which he’ll get the same advantages.

But perhaps Twitter is different, in that it’s a broad discussion or sounding board for ideas, in which we shouldn’t expect people to view what Noakes tweets as prescriptions in the medical sense. That’s presumably what he thinks. I think he’s wrong in practice, because people do view them as prescriptions, and he should know that and act accordingly.

However, it’s possible that holding him to account for all possible consequences of his tweets does overstate the importance and role of Twitter, and also paternalise his Twitter following. For example, a non-prejudicial look at the tweet that started all the trouble is consistent with slowly weaning a child onto LCHF, perhaps in a manner that doesn’t run the risk of causing the complications the complainants in this case claim it would.

So, this case is raising very important background issues related to the appropriateness (or not) of how people with positions of influence engage on social media.It’s not going to be a waste of time, but is rather going to force everyone to resolve what I think are important issues.

It’s a great shame that many of Noakes’ supporters are struggling to see anything beyond a vendetta or bad faith here, and also that Noakes himself misses the point that it’s not about freedom of speech, but rather about the responsibilities of healthcare professionals to avoid causing harm.

He’d retort that it’s the Association for Dietetics in South Africa’s (ADSA) advice that causes the harm, but even if true (and even if he’s even representing what their advice is accurately), that’s something you demonstrate in journals, not with other people’s babies.

Is Noakes speaking “outside his field of expertise”?

One of the things that caused a fuss during the hearing was a statement made by the HPCSA’s lawyer that Noakes was operating or speaking as if he were a dietician, and that this is not his field of expertise. To briefly return to my futility theme, this was immediately leapt on by the Noakes-supporters as an attempt to suppress Noakes’ freedom to research and write on nutrition, while it was in fact nothing of the sort.

The argument was simply that because he’s operating outside of the “normal” General Practitioner (GP) set of ideas but rather as a dietician, it makes sense to include a dietician on the panel. Nevertheless, the motivated reasoning in response to this was quite something to behold, as it was immediately taken up as further evidence of the conspiracy against Noakes, who was now “not allowed” to talk about diet.

The clue as to what GPs do is in the name – they consult on a general set of health-related concerns, one of which is diet. But the claim made by the HPCSA lawyer was that Noakes was presenting himself as more than a generalist, but rather as a specialist in this area, and he should thus be assessed by a specialist also.

What was the problem with the panel composition?

The technical problem that (rightly) led to the cessation of the hearing was that the panel was lacking one particular member as per the regulations, where that member needed to be in Noakes’ profession, i.e. a GP. There was one GP on the panel, who was also a pediatrician, as well as a dietician (who I’ll return to in a moment), but there needed to be another Medical and Dental Board-registered GP present for a properly constituted panel.

What was interesting about the debate on the panel composition?

Both sides seemed intent on creating as favourable a panel as they could, which should of course be no surprise. The complainants argued strongly for the presence of a dietician, and Noakes’ lawyers argued strongly against. Noakes, of course, thinks that the dieticians exemplify bad science in this area, and he’d probably argue that they aren’t competent to assess the evidence he’ll present.

However, the problem with ruling them out is two-fold: one, it presents a circular argument, in that it assumes they are incompetent (or rather, cedes the argument regarding their competence) as reason to rule them out as assessors of the evidence; and two, if they are as incompetent as he thinks, surely it would be a simply matter to demonstrate this in the course of the hearing?

There’s the risk of a strategic blunder from the Noakes team here – the more intent they appear on trying to rule a dietician out as a panelist, the more people might wonder what they are so concerned about. If they are as scientifically backward as Noakes would have us believe, why not publicly expose that via the hearings?

And then….

The strange case of Prof. Blaauw

The dietician panelist, Prof. Blaauw, was initially considered a perfectly acceptable member of the panel, until we discovered two things about her (and the second, only rather late in the day). Over lunch, she informed the (superb) Chair of proceedings, Joan Adams, that she had once co-supervised an ethics thesis on the “media implications of Tim Noakes”. This was claimed to not impair her objectivity, and the Noakes legal team seemed happy with her, despite this knowledge.

Later on, though, we discovered that she was also a member of ADSA, whose President in fact laid the complaint against Prof. Noakes. This caused significant dissent around her suitability, as you’d expect it to given the conflict of interest.

Debate then ensued as to whether she was in fact legally part of the panel at all, as given that it had already been ruled that the panel was improperly constituted, she could not officially or automatically be considered part of a future, properly constituted panel either. Noakes’ lawyers went as far as to say that they might consider taking this issue to the High Court, if Prof. Blaauw ended up remaining on that future panel.

Bad faith and Tex bars

In an amusing turn of events, we reconvened after lunch to find that some prankster had placed Tex bars (a chocolate) on the desks in front of each panelist. Some of the Noakes supporters on Twitter immediately assumed that this was ADSA’s doing, which seemed to fit the generally uncharitable attitude on the #NoakesHearing hashtag, which also included some fat-shaming of various members of the complainant’s party.

Yes, these are emotive issues, and I can understand why people feel that someone they respect and admire for standing up to orthodoxy is being unfairly singled-out, but you don’t make an effective case for his virtue by demonstrating a lack of virtue yourselves. Even if “the other side” sometimes do the same, that does not make your doing so more appropriate either.

One of the Noakes supporters seems to have cottoned on to the reality that people like me don’t have a vendetta, but is rather simply interested in the arguments and ethics of how we debate them. But there’s still far too much ad hominem, and accusations of trolling put in terms that are themselves distinctly trollish. This is the problem of the filter bubble, as I’ve argued before, and I’ll again simply suggest that there is a conversation to be had here, and some of us are having it in good faith – whatever you might believe.

In conclusion

The Noakes legal team seem better prepared, and certainly appeared more effective in their rhetoric and argumentation. Now that the hearings have been extended to run for 7 days, I suspect that the complainants are going to have a difficult time competing. And, at the end of the day, Noakes will “win” on any permutation.

If he is (in the extreme scenario) struck off the roll and disallowed from practicing medicine, that’s of little consequence to his main interest, which is research and (mostly public) dissemination of findings related to diet. And, he and his supporters will have further “evidence” of his persecution.

And if he wins, that will of course serve as his – and the Banting diet’s – most significant tipping point towards public acceptance yet…

Screen Shot 2015-06-05 at 09.50.27

P.S.: The screenshot above is from Noakes’ Real Meal Revolution website, and you might find the last bullet-point of interest.

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  • Tom

    Thanks for summing that up Jacques, it is clearly a win-win for Prof Noakes. If he loses out to the HPCSA it will be easy to spin that as a conspiracy of the system against the little guy trying to get his voice heard.

    Couldn’t agree more about the 2 sides to this #itsnotaboutthediet

  • garyk (Gary Koekemoer)

    But which Tim Noakes is being “tried” here? Grandfather, scientist, GP, athlete, recanted, author or recent social media super star? Who tweeted?
    I suspect the little blue bird is the real winner in this battle of the diets!

  • Slipp Digby

    I think you make some excellent points here about twitter and the obligations of those that give health advice via social media – the need for clarity on this issue certainly seems a more reasonable and justified motivation for the complaint than just a desire to persecute Noakes – but I imagine he feels somewhat aggrieved for what he perceives as being singled out in this way.

    There was a rather interesting interview yesterday which touches on some of the issues you raise:

    It certainly seems from Noakes (around 2:00 mark) that one string of his defence will be that he doesn’t have a doctor patient relationship in any legal sense with those who he gives advice to over twitter. If successfully argued, I presume the HPCSA would thus be unable to take any action against him?

    While I don’t blame him for using every available defence wouldn’t this deny him the opportunity to “debate about what our infants, and in turn adults, should be eating” and to get the HPCSA to “realise that there is something very seriously wrong with the teaching of nutrition in South Africa, as it is in the rest of the world”?

    If he is right about the supression of the truth it is surprising this noble objective – of getting the “truth” heard – doesn’t appear to justify a degree of personal risk on Noakes’s part.

    Further in the video he argues that people get a range of views on twitter and can make an informed choice. This seems a bit flawed in my view. Yes, others did offer the mother in question conventional weaning advice – which she took up – but this counterpoint isn’t always guaranteed to each post and, as you have described the filtering of information means views contrary to our own are less likely to get through based on who we follow (or block!). He also doesn’t seem to realise that his celebrity status makes his views more prominent and accepted.

    There are also interesting examples which show that his claim to be just “giving some information” to people on social media doesn’t quite tell the whole story. Consider these:-

    https://twitter.com/venterchris/status/601084753735864320

    https://twitter.com/younusc/status/601077084845436929

    Ignoring the specifics in these cases there are some interesting things to note:

    – They ask direct specific questions about adverse effects but give limited background.

    – He responds to the individuals and directs them to what he considers the more “likely” explanation (although how the likelihood is ascertained from such limited information is anyones guess).

    – The advice leads one to dismiss another explanation which might help manage the condition (low blood sugar).

    – He fails to note that T1D shouldn’t be banting without their doctors consent.

    – The bias – the most “likely” explanation Noakes favours appears to be the one which fits his prior beliefs despite the symptoms described potentially fitting both or other scenarios

    – These adverse effects are not being added to the Real Deal site (thus minimising perception of harm)

    There is in my opinion a risk of harm when giving individuals uninformed advice via social media and the risk that these very public and visible answers becomes an established part of banting ‘canon’ in wider society. In addition a person with T1D whose is ‘banting’ and not adjusting their insulin dose is strongly indicative that the warning in the Real Meal Revolution about who should bant, and about supervision are not being heeded.

    I think this puts a strong moral obligation on Noakes as doctor, even if not a legal one, to be restrained in the advice he gives. However I think by being such a visible, responsive figure head for this diet and by denigrating ‘conventional advice’ Noakes has let the genie out of the bottle.

    Consider this comment from the above video: “I’ve had to stop my email because I am 1,000 emails behind people asking for advice and information”.

    Worrying stuff.

    • Judit

      Fat help HER long term diet pyramid was it’s older than 40 years.

  • Iacchus Dionysus

    As a lawyer who has been involved in two cases that went to the Supreme Court of Canada on hearing panel bias and natural justice (assessment tax hearing panel for property on Indian reserves, stock exchange hearing panel), drafted the hearing panel rules for an auditor review board and advises with respect to hearings by self-governing professional bodies, the behaviour of the HPCSA here is shocking.

    The HPCSA appointing an ad hoc expert dietician on the panel is anathema to principles of fundamental justice. Security of tenure and financial independence are essential to institutional independence. An ad hoc appointee has a significant incentive to please the body appointing, to be considered for future work. The usual structure for hearing panels is to have a roster of potential panelists, with a fixed tenure on the roster. Second, there should be administrative independence, so that the chair of the roster constitutes panels, not the HPSCA.

    The notion of appointing an expert on the panel is likewise misguided. The physicians are quite capable of understanding expert testimony. To have an expert on the panel invites the expert applying her expertise within panel deliberations without the opportunity of the Noakes team (or the prosecutor) to cross-examine that use of expertise with the assistance of their own experts.

    The notion of appointing someone to the panel from the same organization as the complainant is risible and makes the HPCSA an international laughingstock. They should have at least gone outside the country if they really felt they needed dietary expertise, but putting an expert on the panel is a bad idea from the start.

    This was an amateurish performance by the HPCSA. I expect the HPCSA will be engaging legal counsel with some administrative law expertise and things will be much different in November.

  • garyk (Gary Koekemoer)

    Having encountered your views on Twitter I’ve taken the time to go through some of your writing to understand the case you are making. I agree with parts, I disagree with some fundamentals. I strongly support your mission to improve the argument. I have in turn tried to keep my input as succinct as possible.

    Let me state my own bias upfront. I, after embarking on a lifestyle change which included an LCHF diet lost significant weight and saw some real improvement on many fronts which has now been maintained for over two years. I also have met the Prof briefly and like the guy, I think he’s a genuine soul convinced of the merits of his case. In reading your stuff, I get the sense that you too are sincere in your attempts to improve the argument, and in so doing serving the broader aim of improving scientific method. So I like you and the Prof and I think LCHF has personal merit for me.

    As I see it, Prof Noakes in his tweet did two things; firstly reassured a concerned mother that her breast milk on an LCHF diet would not impact the baby’s gas and wind, and secondly that she should wean (not “ween”) her baby onto an LCHF diet. It appears it is the latter part that incensed the ADSA chairperson and led to the charge before the HSPC.

    The resultant charge as put to Prof Noakes to defend before the HSPC includes at least three issues with regards his “unprofessional conduct”, namely; that he is acting outside his area of expertise, that he is wrong to dispense advice on social media, that LCHF is “unconventional advice” with regards breastfeeding babies.

    But first let me deal with the “noise”. I agree that the Banting Brigade has some real odd bod’s on board and that some of them behave badly on social media on a regular basis. It is the nature of social media (and the 140 character restriction of Tweeting in which you have to make your point and get it noticed), but that doesn’t excuse the lack of constraint nor the rush to conspiracy as a substantiating argument. The bad (or good) behaviour of LCHF/ Banting/ Real Meal/ Noake’s supporters does not in my view negate (nor substantiate) the argument underlying LCHF nor does it decide Prof Noakes conduct. The same applies to the ADSA supporters and the ADSA case.

    Ideally, science should be the arbitrator of whether the LCHF argument is science. Ideally the HSPC should be the arbitrator of whether Prof Noakes has adhered to “norms and standards” of the HSPC club given that he is a member thereof.

    But it is not an ideal world. HSPC has embarked on an adversarial process that will seek to both decide the science and the conduct of one of it’s members. By doing so, it has muddied the waters rather than cleared them.

    If Prof Noakes is a scientific pioneer, then established science will (using Kuhn’s revolution thesis) be resistant to his arguments. The establishment resistance is necessary to ensure that arguments that challenge the status quo have real merit. In turn the Noakes “bubble” is necessary to ensure that the new idea has the legs to stay the course. An HSPC hearing is not the place to decide the scientific argument. That should take place where science usually does it – academia, labs, research, papers, books, conferences, etc.

    If Prof Noakes is a delinquent member of the HSPC, was the “club” clear on it’s rules and did he knowingly transgress them? Does the HSPC “norms and standards” cover advice given on social media, specifically Twitter? If yes, then it should be fairly simple to establish whether he transgressed such and a fairly constituted hearing (in which the accuser cannot be part of the jury) is the place to decide such. If no, then using a hearing to establish precedent is a lazy form of legislating and Prof Noakes would be right to challenge this in court if it rules against him.

    However we are also witnessing I think how “science” is changing. It used to be an old boys club with fairly tight entrance requirements and well contained forums for deciding what is the “truth”. Now, with the advent of Internet and Social Media, anyone with time and tenacity can inform themselves and vent an opinion and scientists are becoming “superstars” with fans. Science is also funded through its commercial application, which brings along a whole bunch of vested interests on both sides. It makes for lovely chaos, the very thing that makes science necessary in the first place…

    .

  • Judit

    Do you know how many practising doctors are now totally keto-ing their patients. Forget banting, that’s just a word – means nothing. There’s a dr. Donald Miller (a cardiothoracic surgeon) who apologised to all his patients for putting them onto low fat after bypass and heart surgery. His hospital has a kitchen section for him especially where his patients immediately go onto high sat fat diets post op. Noakes simply championed it in South Africa, but the doctors of the world who are now proponents are legion. Each to his own but as for me and mine we have familial hypercholesterolemia and 70% fat a day halved our cholesterol. I was thrown a tether. And that has NOTHING to do with a girl who gives cakes to the poor. I’ll go and stand with her. To make anything a religion is futility at best. Unfortunately obesity in my mind has hijacked this way of life when there are thin people with ailments for whom high fat could be life saving (look at the many epileptics who have been SAVED by keto).

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