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How not to treat cancer (or anything else)

[ 40 ] August 3, 2010 |

So long as we’re debating the legal and ethical conduct of certain Australians of recent public note, there’s this bit of unsurprising news:

Penelope Dingle died in August 2005 after initially refusing surgery for rectal cancer, opting to be treated with alternative remedies instead. The 45-year-old underwent emergency surgery in October 2003 to remove a life-threatening tumour but the cancer had already spread to other parts of her body.

Delivering his findings on Friday, West Australian Coroner Alastair Hope said homeopath Francine Scrayen “was not a competent health professional” and had given “dangerous advice” to Mrs Dingle when treating her.

He also said Mrs Dingle’s husband Peter, a prominent toxicologist, was “a victim of his own misinformation” and had “no qualifications in health and wellness”.


Peter Dingle appears to be something of a B-lister in the universe of Aussie quacks, an environmental toxicologist who believes that chemotherapy and radiotherapy are ineffective at treating nearly every form of cancer; that autism in children is caused by poor diet; that sunscreen will kill you; and that the ordinary flu vaccine caused people to contract H1N1. He markets a variety of books on his website, most of which make utterly fantastic claims about how to prevent and treat illness solely through diet and “natural” interventions. Evidently, his wife’s colorectal cancer provided him with further literary inspiration: At the coroner’s inquest, one witness testified that Dingle and his wife’s homeopath, Francine Scrayen, were planning to write a book attesting to homeopathy’s role in curing the disease without surgery, radiation or pharmaceuticals.  (The future of that book project would seem uncertain at this point.)

Penelope Dingle was by all accounts a willing participant in a variety of sham therapies that did nothing but allow her cancer to spread without interruption for 18 months. Rather than see a proper physician, she received encouragement from her husband and Scrayen to treat her rectal hemorrhaging and bowel obstruction with vitamin C and venus flytrap, with an occasional psychic reading or velvet soap enema thrown in for variety. By the time her cancer had metastasized and the main tumor was large enough to rip her bowels open, she weighed about 75 pounds. The head of the Australian Homeopathic Association has evidently suggested that Scrayen might have violated the organization’s Code of Conduct, which — among other things — advises homeopaths not to claim that their magical potions water drops and sugar pills are effective at treating real diseases.

What makes this case especially timely is that Australia is one of at least three nations — Germany and the UK being the others — where legislators are being urged to end all public subsidies for homeopathy, which deserves public funding to the same degree that, say, dowsers ought to be employed by state agricultural bureaus. Medibank, the private insurer owned by the Australian government, doesn’t reimburse patients for homeopathic placebos (though it does reimburse for consultations with “alternative” practitioners); many other private insurers in Australia cover homeopathy, however, and government subsidies for patient premiums means there’s a public cost for modalities that have never been able to bear the slightest scrutiny. The Australian Medical Association has, quite reasonably, come out against further subsidies for homeopathy.

The Dingle inquest — combined with an equally horrific manslaughter case that concluded last year — should bring more attention to the scam, but homeopathy is something of an unsinkable rubber duck. In the UK, for example, the House of Commons’ Science and Technology Committee published a brutal report in February that recommended the NHS abandon all funding for homeopathy (which by most estimates receives about £4 million annually from the government, a figure that doesn’t include other expenses like the £20 million squandered on renovations to the London Homeopathic Hospital early last decade). The British Medical Association agreed. In spite of it all, the government decided a week ago that although homeopathy is worthless, that the NHS embarrasses itself by associating with it in any way, and that homeopathy doesn’t deserve public support, Whitehall won’t actually prohibit the NHS from supporting it. It’s a preview of what I expect will happen in Australia and Germany (if the debates even carry that far).

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Comments (40)

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  1. Ignobility says:

    The health insurance from the hospital where I work pays for “alternative medicine” but now charges extra for vision coverage. On the other hand, flu vaccine is now mandatory for all employees. There are people who work here, in a hospital, who are very upset that they are now required to get a flu shot. I don’t understand how pseudo-science has taken hold to this extent.

    Finally, one co-worker’s husband decided to treat his cancer with alternative therapies. He is deceased. Another co-worker’s husband was diagnosed with the same cancer, and opted for immediate surgery. He’s doing fine, now. I just hope he doesn’t need glasses.

  2. Emma says:

    About half of Australians have private health insurance despite the government subsidy. Most private health insurance doesn’t cover alternative therapy to the full cost of it, so there’s generally a gap that discourages people from using it. Our public health system (which is generally excellent — I had my gall bladder out in a publisc hospital last week after waiting less than a month from diagnosis, for example, and the cost was $300*) doesn’t fund any of this woo nonsense, thank goodness. Not that that would be any comfort to the people who cared about this poor woman.

    *My two weeks of paid sick leave explains the heavy commenting on LGM — I’m not at work!

  3. Draker says:

    Yes I will echo what Emma says. My private health plan covers all sorts of ouiji board stuff, but never to the full cost of it. One thing I did stupidly indulge in when I was much younger was Chiropractic “care” which was covered, as most plans do (with the gap mentioned above).

    My question is, I don’t think most Australians are aware that Chiropractics is mostly nonsense. It is used everywhere here. You should have seen how packed my old Chiropracter’s was. Is this a common situation in other countries? Or are Australians uniquely credulous in this respect?

  4. Matt McKeon says:

    A chiropractor makes you feel better after he gives you basically a massage. It’s a version of taking a 19th century patent medicine spiked with cocaine or spirits. And his system of beliefs may not make any sense, or give you any real benefit, but at least he’s not telling you he’s curing cancer.

    • Emma says:

      Although there is evidence that chiropractic causes stroke in otherwise healthy patients. Which would be a good reason to outlaw it, in my opinion.

    • It reminds me of a Simpson’s episode where, after Homer goes to a chiropractor for a back injury, he (Homer) exclaims “It feels slightly better!”

    • Woodrowfan says:

      I remember back in the 1970s one of my mom’s friends died of a brain tumor that was treated by a chiropractor. And no, it didn’t do a thing except allow the cancer to spread.

  5. SeanH says:

    The problem with homoeopathy on the NHS is that Nice (Nation Institute for Clinical Excellence) evaluates cost-effectiveness in such a way as to give snake oil a pass. It sees money going in, and happy patients coming out, a metric that favours homoeopathy (and is of course totally blind to the actual efficacy of these “medicines”).

  6. blowback says:

    But our possible future King believes in the efficacy of homeopathy so £4Million to shut him up is money well spent.

    • Jon H says:

      Given his reputation for ultra-conservative preferences in architecture, some bright architect ought to take the Prince’s penchant for homeopathy into account.

      Design a modern building, but say the concrete will contain homeopathic levels of Georgian brick.

  7. ramster says:

    I applaud your vigilance against quackery of all forms. I expect that if you scour the presses, you’ll find perhaps a few dozen more instances of death by homeopathy around the world. In my own backyard, a 9 year old died of diabetes a few years ago due to exclusively homeopathic treatment. The generous view of homeopathy is that it’s pure placebo effect in action, whose effect is enhanced by the fact that it’s generally accompanied by much longer patient/practitioner interaction (i.e. actually listening to them). Atrocities like the Aussie cancer case notwithstanding, it’s also generally applied to more benign conditions and/or in conjunction with allopathic treatments.

    Homeopathy has a long way to go before it can approach the industrial scale killing machine that is the modern medical system. Some quick numbers:

    annual death from medical error in US: 200000
    annual deaths from hospital infections in US: 100000

    I’m not sure the degree to which there’s double counting in the above figures and the data is innaccurate (though probably undercounted). Then there’s the case of deaths due to dodgy pharmaceticals which are approved since the pharmas own research showing their inefficacy or actual lethality are suppressed. Examples are unfortunately numerous and the death toll is difficult to quantify.

    I certainly don’t dispute the entertainment value in debunking quakery and the notion that a sugar pill without a single molecule of its supposedly active ingredient can have a physiological effect leaps beyond any reasonable understanding of biology, chemistry and physics. I just don’t quite get the emphasis. Maybe the quacks are just easier targets than multi-billion (trillion??) dollar established industries and professions. I myself am far more outraged by the thousands of deaths causued by practitioners of rational, evidence based scientific medicine, because the can’t be bothered to wash their friggin hands, than a handful of quackery induced deaths.

    • Marc says:

      Countering the quackery, aggressively, ensures that it remains on the fringe and kills fewer people. Think of it as the intellectual equivalent of weeding a garden.

    • davenoon says:

      I assure you I’m not writing about this stuff because I’m afraid of pharmaceutical corporations and medical professionals. I suppose the simplest explanation is that modern medicine has driven down the neonatal mortality rate to near zero; virtually eliminated obstetrical death; obliterated diseases that collectively used to kill millions worldwide on an annual basis; raised life expectancy in the US alone by about 75 percent since 1900; allowed people to thrive with conditions that would have made life unendurable in previous eras; and so on and so forth. I’m usually not one to cheerlead for human ingenuity, but this is a pretty impressive record.

      I don’t know a single health professional who isn’t concerned about medical errors or infection rates, and professional organizations have done an immense amount of work over the past decade to address these problems in the wake of several major studies (e.g., the IOM report in 1999 on infections, or the JAMA study on medical errors); homeopaths and the like, by contrast, haven’t a reflexive bone in their bodies and adhere to theories of disease that are, as you point out, deliberately ignorant.

      And that’s what gets my goat. As an expression of human stupidity, I don’t see much difference between (a) believing that tax cuts for the rich generate economic growth and (b) believing that spinal subluxations cause colic in infants, or that cancer can be arrested by vitamin C and essence of venus flytrap. I won’t argue that the effects of (b) are identical to (a), but the effects of (b) aren’t negligible.

    • mpowell says:

      Hospitals are treating a lot more patients, so I don’t really agree with your claim that they do worse by the average patient (and I don’t really think you would disagree). But these are only people working in the hospitals. Some of them are bad people, some of them are good people who make mistakes or are under a lot of pressure at times. It is difficult to eliminate either case. And a lot of these excess deaths are going to be very weak, elderly people. With the best possible doctors, any given patient would have a better chance of survival. But the best possible doctors are in short supply. You have to do a lot more work to establish that the system is actually falling short (and I think it may be, but not in the way you are suggesting).

    • Halloween Jack says:

      Polio. Smallpox. The Black Death. Those are the diseases that were cured by modern medicine, which your quote-endquote alternative and complimentary medicines did fuck-all against. Those are the deaths next to which your nosocomial infections and iatrogenic conditions are, relatively speaking, a drop in the bucket. But thanks for playing!

    • The Pale Scot says:

      The hospital infections aren’t a result of unwashed hands, it’s that ungodly bugaboo evolution. Bacteria are evolving methods of surviving chemical sterilization. Research has found strains of staph living in containers of full strength cleaners at hospitals. Once these enzymic pathways are created in one strain, they can be transferred thru plasmids, little bags of DNA that are excreted by one cell and absorbed by another, and viruses. Each on of us has billions of individual bacteri inside swapping genes, and trillions on every surface. There’s a strain of staph that uses penicillin as a food source. It’s running the military ragged.

      It’s likely that the last 70 years were a temporary respite from death by infection, the pharmaceutical industry is spending a pittance on new anti-biotics, not enough profit in just curing someone, life long treatments and cosmetics are where the big money is.

      In the end, the bugs will win.

    • AndyD says:

      Billions of people a year are treated in the mainstream medical system. Many of them are suffering critical and complicated conditions that require quick-action. Mistakes will be made, infections will occur, death might result.

      And no one would surely presume that every human that works in the mainstream profession is perfect and/or 100% dedicated. What profession can make that claim?

      But at least the majority of patients in the mainstream system receive real, tangible benefit from it.

      Homeopathy, however, isn’t a mistake or laziness. It looks like willful ignorance perpetrated on the unsuspecting for no genuine benefit at all – well, not to the patient at least.

  8. cervantes says:

    It is true that many deaths are caused by medical errors. Some errors are inevitable, of course, since humans and human-created systems will always be imperfect. However, there is a big difference between error and fraud.

    The risk of error, and the risk of failure or unanticipated adverse effects that comes with medical intervention is weighed against the likely benefits. Physicians do have a bias toward action, so this balance is not struck perfectly; and we still have a long way to go in improving patient safety and assuring that appropriate practices, such as frequent hand washing, are followed. Nevertheless medicine is continually expanding its evidence base and its quality control methods to improve patient safety and outcomes. And obviously, on balance, medical intervention does far more good than harm. For every patient who is harmed or whose death is hastened by medical intervention, there are dozens to hundreds who benefit.

    Homeopathy is doing no such thing. It’s pure nonsense from the beginning. Rather than making an effort to be self-critical and improve outcomes for patients — which it cannot possibly do because there is nothing there to work with in the first place — homeopaths simply pile on the deception and the lies.

    So this really is a deeply false comparison.

  9. ramster says:

    Many points to respond to.

    - there are several references to fraud, deception, lies, etc. Obviously these are incendiary accusations. Homeopaths tend to believe that they are operating within a consistent and valid theoretical framework, albeit one that is not consistent with the best current understanding of science. And they also believe that they are working in the best interest of their patients. They may be misguided in this belief but I think its a slander to lequate that with fraud and downright evil. In contrast, deliberately withholding research documenting the lack of efficacy and/or danger of pharmaceutical drugs certainly seems to cross the line into unethical behaviour.

    - I tend to view homeopathy as an entire discipline dedicated to improving people’s health through the use of placebos. Given what we know of placebos and the fact that the placebo effect is getting stronger, this is hardly trivial in terms of actually improving patient outcomes.

    - “Nevertheless medicine is continually expanding its evidence base and its quality control methods to improve patient safety and outcomes. And obviously, on balance, medical intervention does far more good than harm.” This is far from certain. An enormous part of medicine’s evidence base comes from pharmaceutical research. The systematic suppression of negative research results continually undermines the evidence base to a degree that we may in fact be going backwards. As far as interventions causing more good than harm on balance, that is also unclear. The proliferation of diagnostic tests is leading to treatments where on balance, it’s not clear that the results are better than doing nothing at all. One specific example is treatment based on positive PSA tests for prostate cancer. Another example is Atul Gawande’s recent article describing how terminal patients appear to have better outcomes waiting to die in hospices instead of receiving treatment

    - It’s common to trot out the preceding centuries worth of remarkable advances in medicine and its impact on human health to defend the establishment medical system but I don’t buy it. What matters is what we do looking forwards to improve patients outcomes and people’s health more generally into the future. With that goal in mind, an oncologist truly interested in their patients welfare might want to consider recommending homeopathy for patients so inclined in addition to their standard course of treatment, in order to maximally harness the combination of allopathic medicine and the placebo effect. Of course to do so, they’d have to set aside their jihad against quackery.

    • djw says:

      With that goal in mind, an oncologist truly interested in their patients welfare might want to consider recommending homeopathy for patients so inclined in addition to their standard course of treatment, in order to maximally harness the combination of allopathic medicine and the placebo effect.

      There’s a lot of nonsense in your post, but I’ll focus on this one, as it presumes that only homeopathic quackery is capable of delivering a placebo effect. I’d be curious to see how that claim could be defended.

    • Halloween Jack says:

      You’re pleading on the basis of good intentions and comparing a school of treatment which rigorously documents its errors and mistakes–which, in fact, is not only required to do so by law, but also to publicly report those statistics–to one that doesn’t. And the facts are far from unclear. What you choose to “buy” is your business, of course; just be careful that you don’t go off the edge of the earth the next time you go sailing. I hear there be dragons there.

    • mpowell says:

      Looking forward, there may be things we can do to improve standard practice medicine. But practices like homeopathy force us to look backwards to realize there are a huge number of frequently lethal conditions that modern medicine is very good at addressing or curing… and homeopathy is not. That comparison absolutely must be kept in mind when considering whether homeopathy should be funded, or even permitted for minors.

    • Oscar Leroy says:

      “Homeopathy is based on the idea that a substance that in large doses will produce symptoms of a specific disease will, in extremely small doses, cure it.” (from Wikipedia)

      Does that even make any sense at all? “You have a headache, huh? Well when I swallow this root I get a headache, so you should take a tiny bit of root and mix it with water and drink it!” Some people must just want to stay sick.

    • RepubAnon says:

      Homeopathy explained:
      http://xkcd.com/765/

  10. ramster says:

    oops, bad links:

    first one:

    second one:

    • cer says:

      I have no idea where you get the interpretation that Gawande’s piece on hospice care could in any way be seen as a criticism of mainstream medicine. What hospice care does is provide pain relief and given that pain takes a serious physical and psychological toll on the body, it is not surprising at all that hospice patients have good outcomes, relatively speaking. Hospice care, especially for terminal cancer patients who are his primary focus, is about making a choice between potentially harmful possible treatments that may prolong one’s life or accepting death and utilizing palliative care in the form of pharmaceuticals. Having just experienced the provision of hospice care for a family member it annoys me to no end to see hospice care characterized as an alternative to or termination of mainstream medical treatment. The need for hospice care is, really, a consequence of the success of traditional medicine that gives us options about managing medical conditions. Nor is hospice care “doing nothing.” The administration of high doses of pain relief is treatment.

  11. davenoon says:

    The idea that the placebo effect is “getting stronger” worldwide is just not supported by the research; the article you link to offers an impressionistic judgment (by drug developers, no less) that this is happening, but the actual scientific voices in the piece tell us nothing new. The placebo response is unpredictable, culturally contingent, relevant to medical issues where there’s a strong pyschogenic overlay, and visible (so to speak) only for subjectively-reported symptoms. Moreover, it’s never been clear that what we think of as “the placebo effect” isn’t an artifact of the research situation itself — including researcher bias or the subject’s desire to please the researcher or be otherwise helpful to the study. Here’s the latest, most comprehensive review of the literature on placebo. You won’t be comforted by its conclusions.

    To put it bluntly, there’s absolutely no clinically compelling reason to take homeopathy seriously, even if the placebo effect were an actual, consistent phenomenon. Moreover, the ethical issues that would be involved with — as you put it — “harnessing” the placebo effect are not irrelevant, since this would involve outright deception. And given the variability and unpredictability of whatever effect may or may not actually exist, the ethical problems with “harnessing” placebo are staggering to contemplate. Using the idea of hospice care — which is up front about its role as palliative, end-of-life care — to import homeopathy through the back door is really quite absurd.

  12. Murc says:

    I’m going to maybe stick my neck out and possibly get it cut off by Dave, who probably knows a lot more about this sort of thing than I do.

    It seems unfair to classify ALL forms of homeopathy as quackery. I am aware that once something is PROVEN to work it is no longer considered ‘homeopathic’ or ‘alternative’ medicine, simply ‘medicine’, but I forge ahead gamely anyhow.

    Substituting anecdotes for data time; my father is a podiatrist. He has a long-running private practice and regularly preforms surgeries and consults regularly at local hospitals. He will, from time to time, either in the case of surgeries that have failed to correct underlying problems or for people whom he deems surgery especially risky, refer people to a colleague of his who, in addition to being a podiatrist, is ALSO a chiropractor. This colleague, a longstanding associate who takes his work seriously, often achieves solid results with chiropractic therapy relating to the feet. He takes his job seriously and tries to adhere to medical best practices in all he does. It seems unfair to dismiss his entire field as quackery.

    (To be fair, he both 1) sometimes achieves no results at all, and 2) he is something of an outcast in the local chiropractic community for calling a number of them ‘charlatans’ and ‘dangerous’ in public, and is openly contemptuous of many of them for ONLY have chiropractic ‘degrees’ as opposed to a full medical one; so he might be a bit of an odd duck.)

    As a side note, I’d like to bring up acupuncture as well. I’ve known, not just heard of, but KNOWN, people who received immense and ongoing relief from back problems thanks to the use of acupuncture. These are people who, far from being credulous crystal-waving hippies, exhausted every traditional medical option available to them before turning to it. Placebo effect? Black swan effect? I guess maybe. but…

    Anyway. Just my two cents.

    • davenoon says:

      Homeopathy is a very specific practice based on the idea that diluted substances can actually cure diseases, so long as the original substance mimics the effects of the disease itself. I think you’re confusing homeopathy with alt-med more broadly….

      As for your other points, my standard response is to look at the published record. It’s not very favorable to any of these modalities.

      • Oscar Leroy says:

        Chiropractic can work for certain things. If your back or foot hurts, you can do worse than have those bones adjusted by someone knowledgeable of anatomy until they feel better. But once you get into stuff like “manipulating your spine increases resistance to disease” you are moving away from actual science into quackery.

    • Tom M says:

      As an amputee with phantom limb pain, I was willing to try any and all alternatives, medicine, acupuncture (with an MD- bloody useless) hypnosis, and everything else. Nothing had any effect. If it wasn’t for the drugs, it would be unbearable.
      You have your anecdote, I have mine and that’s all they are: anecdotes. Not proof. Worthless.

  13. Dan S. says:

    “in conjunction with allopathic treatments.”

    “allopathic treatments” are, of course, otherwise referred to as “medicine”. Which of course isn’t perfect, but if the little one is having a really horrible time teething, I’d much rather give her baby acetaminophen than (for example) little tablets of lactose w/ 1 part in a 1000 of (poisonous, so the ridiculous dilution is quite lucky here!) belladonna, calcium phosphate, coffee and chamomille (which could be genuinely helpful – except it’s not present in useful amounts and is actually not recommended for teething babies.

    And Oscar – that wikipedia link is well worth it, even if just for the mention of

    …more esoteric bases for remedies, known as imponderables because they do not originate from a material but from electromagnetic energy presumed to have been “captured” by alcohol or lactose. Examples include X-rays… and sunlight….Recent ventures by homeopaths into even more esoteric substances include thunderstorms (prepared from collected rainwater)

    (I have to admit kinda loving the idea of being “treated” by “sunlight” and “thunderstorms” – which can, let’s be fair, be therapeutic in their real forms!)

    and that

    … some homeopaths also use techniques that are regarded by other practitioners as controversial. These include paper remedies, where the substance and dilution are written on a piece of paper and either pinned to the patient’s clothing, put in their pocket, or placed under a glass of water that is then given to the patient …

    (not unlike the practice of keeping paper with verses of one or another holy scripture on one’s person for protection or as medicine . . .)

  14. herr doktor bimler says:

    Homeopaths tend to believe that they are operating within a consistent and valid theoretical framework, albeit one that is not consistent with the best current understanding of science. And they also believe that they are working in the best interest of their patients. They may be misguided in this belief but I think its a slander to lequate that with fraud and downright evil. In contrast, deliberately withholding research documenting the lack of efficacy and/or danger of pharmaceutical drugs certainly seems to cross the line into unethical behaviour.

    So when homeopaths ignore or find rationalisations for the overwhelming evidence that homeopathy doesn’t work, in order to maintain their income stream, they are guilty only of self-delusion; but when people in the medical industry ignore evidence that a drug doesn’t work, it is malice?
    Why the double standard?

  15. Dave says:

    I’m not sure about the value of homeopathy, but I am sure about the stale, dated approaches of allopathic medicine to cancer treatment and the blatant, rampant conflicts of interest that are present in the cancer industry. The proverbial foxes are in charge of the hen house here. There are massive political and financial incentives for researchers and the people in control of the cancer establishment to perpetrate the status quo, and that is exactly what they do. You can take all the money that all alternative cancer practitioners have made, and it wouldn’t equal a tenth of one percent of the many hundreds of billions/trillions of dollars that the Medical Establishment have made over the years.

    I’m not saying that all alternative cancer treatment methods are effective. But it is an insult to the intelligence of any thinking person to truly believe that NO ONE IN HISTORY has EVER come up with an effective, non-toxic treatment method for cancer over a 100 year period! Even if one just took the IUPAC list of chemicals and ran through them, you would eventually find one that was non-toxic and effective for cancer treatment. But you will find many credentialed, highly-acclaimed scientists who were politically destroyed because their treatments were a threat to huge financial interests that earn their money, status and power based on the status quo.

    There is definitely a better approach to cancer treatment than chemotherapy drugs(based on chemical warfare agents), radiation(everybody knows how toxic this is) and surgery(butchery). How about something that does not destroy the immune system like chemo, but something that strengthens it? The toughest part of this is that many studies by the ‘authorities’ are stacked to insure that no ‘credible’ studies that prove that any alternative treatments are effective. Meanwhile, many thousands and millions of people have to suffer and die of cancer. For all of the hoopla about these ‘modern’ cancer treatments, they still haven’t found a cure, or even anything outside of the ‘holy three’ treatments. I wonder why that is, after 50+ years of research and many billions spent, we still have the exact same treatment methods. It doesn’t take a Ph.D. to understand this, but it does take someone willing to step outside of the conditioning and reverence to authority figures that work incessantly to enforce their ideas upon the minds of the unsuspecting public and those naive enough to believe that any scientific research can be 100% objective.

  16. [...] Conventional Treatments, The Cancer Industry I couldn’t contain myself after going to a blog that discusses cancer treatments. They were essentially talking negatively about homeopathic treatments for cancer in this blog [...]

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